key: cord-0981180-kjdc2mke
authors: Pan, Daniel; Martin, Christopher A; Nazareth, Joshua; Nevill, Clareece R; Minhas, Jatinder S; Divall, Pip; Sze, Shirley; Gray, Laura J; Abrams, Keith R; Nellums, Laura B; Pareek, Manish
title: Ethnic disparities in COVID-19: increased risk of infection or severe disease?
date: 2021-07-29
journal: Lancet
DOI: 10.1016/s0140-6736(21)01428-8
sha: bf559583234714ff1e0d17ad7421a535c7a5d6a2
doc_id: 981180
cord_uid: kjdc2mke

nan

equity of opportunity" for scientists in LMICs who must be central to all aspects of the R&D ecosystem. 1 A global financing system is essential to support the broad components of the R&D ecosystem of the future. Distributed modern manufacturing capacity, including in LMICs, and procurement and distribution of the products of R&D are integral to this. Eliminating the "immoral inequity" of vaccine access that IJsselmuiden and colleagues refer to depends on sufficient manufacturing capacity to address the needs of all countries simultaneously. We are heartened by the call of the Africa Centres for Disease Control and Prevention to establish more vaccine manufacturing capacity on the African continent. 2 LMICs also need to invest their own resources; indeed, in the Money & Microbes report, 3 the World Bank's International Vaccines Task Force notes the importance of national investments to "motivate young investigators to pursue clinical research careers, and…to choose to use those skills in-country". Providing the quality education and infrastructure cutting-edge scientists require will make it easier to retain talented young scientists and attract nationals who wish to return home after their education and training abroad. While the world cannot wait for these goals to be achieved to improve the R&D preparedness and response ecosystem, we can ensure that national and international investments and a solid financing system will leave us better positioned to achieve both equity of opportunity and equity of outcomes. We must use this time during the COVID-19 crisis to make solid progress towards that end. GTK groups might be biologically more likely to develop severe disease once infected compared with White groups (appendix). Future studies must aim to disentangle the two risks because, if minority ethnic groups are disproportionately affected by COVID-19 mainly because of an increased risk of infection, it will be clearly due to inequalities that predispose them to exposure-such as living within multigenerational settings or being an essential worker. A focused public health approach that prioritises lowering the risk of SARS-CoV-2 infection in those predominantly at risk of exposure would also prevent disproportionate death. KRA 

Rohini Mathur and colleagues found that Black and Asian ethnic groups were more likely to have adverse COVID-19 outcomes compared with the White population, even after accounting for differences in sociodemographic, clinical, and household characteristics. 1 These findings are timely and striking, in light of the Commission on Race and Ethnic Disparities' recent report, 2 which has been criticised for suggesting that the "claim the country is still institutionally racist is not borne out of evidence". 3 We note that Mathur and colleagues did not adjust for the risk of testing positive for SARS-CoV-2 during the second wave. 4 If, by adjusting for the risk of infection, the higher risk of severe disease in South Asians compared with White groups is nullified, this suggests that, potentially, factors relating to increased exposure to the virus, such as being an essential worker, could explain most of the increased risk. However, should the risk of intensive care admission and death remain high, this suggests that South Asian Alternatively, we would have needed to adjust for all factors associated with testing positive for SARS-CoV-2, 3 including occupation, 4 which is not captured in routine electronic health data.

Our study provides other clues that ethnic differences in severe COVID-19 outcomes might be driven by exposure risk, including the attenuation of risk on adjustment for household size and the rapid change in ethnic patterning of outcomes from the first wave to the second wave, which would be unlikely if ethnic differences were more related to the effects of underlying susceptibility than to increased exposure.

There are now a number of population-based cohorts in the UK, within which it might be possible to reliably estimate COVID-19 severity in a representative sample of people with known infection. These include the REACT-2 study, which has already reported higher levels of SARS-CoV-2 antibodies in minority ethnic groups but no ethnic differences in infectionto-mortality ratios. 5 Studies from the Office for National Statistics and the UK Biobank highlighting the role of occupational exposure in COVID-19 mortality further support the hypothesis that ethnic differences in severe COVID-19 outcomes might be related to differences in exposure risk rather than other explanations, such as biological differences or health-care related factors. 6, 7 We look forward to findings from ongoing prospective cohort studies, which will build upon existing insights from sociological and community engagement work to disentangle the complex interactions between ethnicity, social disadvantage, occupational and household factors, and access to health care in explaining health inequalities related to COVID-19 and beyond. 8 RM reports research funding from the Wellcome Trust and personal fees from AMGEN, unrelated to this Correspondence. All other authors declare no competing interests.

using the OpenSAFELY platform

Urgent actions and policies needed to address COVID-19 among UK ethnic minorities

Collider bias undermines our understanding of COVID-19 disease risk and severity

results from the ONS Coronavirus Infection Survey

SARS-CoV-2 antibody prevalence in England following the first peak of the pandemic

Occupation and COVID-19 mortality in England: a national linked data study of 14·3 million adults

Occupation and risk of severe COVID-19: prospective cohort study of 120 075 UK Biobank participants

Interpreting differential health outcomes among minority ethnic groups in wave 1 and 2

The report of the Commission on Race and Ethnic Disparities

Downing Street suggests UK should be seen as model of racial equality

COVID-19 policy tracker 2020: a timeline of national policy and health system responses to COVID-19 in England in 2020

We thank Daniel Pan and colleagues for raising an important point regarding our cohort study. 1 We agree that separating the risk of infection from the risk of severe disease among those infected is a key issue in understanding and tackling ethnic disparities in COVID-19. 2 Separating these risks in routine electronic health data sources is challenging. During the first wave of the pandemic in the UK, testing for SARS-CoV-2 was not random, with prioritisation of health-care workers and those admitted to hospital. Although testing was more common during the second wave, those receiving a test were still not entirely representative of the population infected with SARS-CoV-2.Indeed, in our own study, we found that minority ethnic groups were less likely to be tested for SARS-CoV-2 than White groups were in the second wave. 1 Therefore restricting our analyses of severe COVID-19 outcomes to those who tested positive for SARS-CoV-2 could have introduced bias and limited interpretation of the resulting estimates. 3 To generate unbiased estimates of ethnic differences in COVID-19 severity among those infected, we would have needed to be confident that uptake of testing in relation to infection prevalence was equivalent between ethnic groups at the point of analysis.