Ethnicity and clinical outcomes in COVID-19: A Systematic Review and Meta-analysis
Authors: Sze Shirley , Pan Daniel , Gray Laura J , Nevill Clareece R , Martin Christopher A , Nazareth Joshua , Minhas Jatinder S , Divall Pip , Khunti Kamlesh , Abrams Keith R , Nellums Laura B , Pareek Manish 
Published: September 2020

ABSTRACTImportanceThe association of ethnicity with outcomes in patients with COVID-19 is unclear.ObjectiveTo determine whether the risk of SARS-CoV-2 infection, COVID-19 intensive care unit (ICU) admission and mortality are associated with ethnicity.Data SourcesWe searched all English language articles published 1st December 2019 - 30th June 2020 within MEDLINE, EMBASE, PROSPERO and the Cochrane library using indexing terms for COVID-19 and ethnicity, as well as manuscripts awaiting peer review on MedRxiv during the same period.Study SelectionIncluded studies reported original clinical data, disaggregated by ethnicity, on patients with confirmed or suspected COVID-19. We excluded correspondence, area level, modelling and basic science articles. Two independent reviewers screened articles for inclusion. Of 926 identified articles, 35 were included in the meta-analyses.Data Extraction and SynthesisThe review was conducted according to PRISMA guidelines. Reviewers independently extracted data using a piloted form on: (1) rates of infection, ICU admission and mortality by ethnicity; and (2) unadjusted and adjusted data comparing ethnic minority and White groups. Data were pooled using random effects models.Main Outcomes and MeasuresOutcomes were: (1) infection with SARS-CoV-2 confirmed on molecular testing; (2) ICU admission; and (3) mortality in COVID-19 confirmed and suspected cases.Results13,535,562 patients from 35 studies were included in the meta-analyses. Black, Asian and Hispanic individuals had a greater risk of infection compared to White individuals (Black: pooled adjusted RR: 2.06, 95% CI: 1.59-2.67; Asian: 1.35, 95%CI: 1.15-1.59; Hispanic: 1.77, 95% CI: 1.39-2.25). Black individuals were significantly more likely to be admitted to ICU than White individuals (pooled adjusted RR: 1.61, 95% CI: 1.02-2.55). Risk of mortality was similar across ethnicities among hospitalised patients, but increased among Asian and Mixed ethnic groups in the general population.ConclusionsBlack, Asian and Hispanic ethnic groups are at increased risk of SARS-CoV-2 infection. Black individuals may be more likely to require ICU admission for COVID-19. There may also be disparities in risk of death from COVID-19 at a population level. Our findings are of critical public health importance and should inform policy on minimising SARS-CoV-2 exposure in ethnic minority groups.KEY POINTSQuestionIs ethnicity associated with vulnerability to, and outcomes from, coronavirus disease 2019 (COVID-19)?FindingsIn this systematic review and meta-analysis, rates of infection and outcomes from COVID-19 were compared between ethnic groups. Individuals from Black, Asian and Hispanic ethnicity were significantly more vulnerable to SARS-CoV-2 infection than those of White ethnicity. Black individuals were more likely to need intensive care unit (ICU) admission for COVID-19 than White individuals. Risk of mortality was similar across ethnicities among hospitalised patients, but increased among Asian and Mixed ethnic groups in the general population.MeaningThere is strong evidence for an increased risk of SARS-CoV-2 infection amongst ethnic minorities, and targeted public health policies are required to reduce this risk.