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Ethnicity and Outcomes from COVID-19: The ISARIC CCP-UK Prospective Observational Cohort Study of Hospitalised Patients

41 Pages Posted: 17 Jun 2020

See all articles by Ewen M. Harrison

Ewen M. Harrison

University of Edinburgh - Centre for Medical Informatics

Annemarie B. Docherty

University of Edinburgh - Centre for Medical Informatics

Benjamin Barr

University of Liverpool - Institute of Population Health Sciences

Iain Buchan

University of Liverpool; University of Manchester

Gail Carson

University of Oxford - Centre for Tropical Medicine and Global Health

Tom M. Drake

University of Edinburgh - Centre for Medical Informatics

Jake Dunning

Public Health England - National Infection Service

Cameron J. Fairfield

University of Edinburgh - Centre for Medical Informatics

Carrol Gamble

University of Liverpool - Liverpool Clinical Trials Centre

Christopher A. Green

University of Birmingham - Institute of Microbiology & Infection

Chris Griffiths

Queen Mary University of London - Barts and The London School of Medicine and Dentistry

Sophie Halpin

University of Liverpool - Liverpool Clinical Trials Centre

Hayley E. Hardwick

University of Liverpool - NIHR Health Protection Research Unit for Emerging and Zoonotic Infection

Antonia Ho

MRC University of Glasgow Centre for Virus Research

Karl A. Holden

University of Liverpool - Women’s and Children’s Health

Joe Hollinghurst

Swansea University

Peter W. Horby

University of Oxford - Centre for Tropical Medicine and International Health

Clare Jackson

University of Birmingham - Institute of Microbiology & Infection

Srinivasa Vittal Katikireddi

MRC/CSO Social & Public Health Sciences Unit, University of Glasgow

Stephen Knight

University of Edinburgh - Centre for Medical Informatics

Ronan Lyons

University of Swansea

James MacMahon

Public Health Scotland

Kenneth A. Mclean

University of Edinburgh - Centre for Medical Informatics

Laura Merson

University of Oxford - ISARIC Global Support Centre

Derek Murphy

University of Edinburgh - Centre for Medical Informatics

Jonathan S. Nguyen-Van-Tam

University of Nottingham - School of Medicine

Lisa Norman

University of Edinburgh - Centre for Medical Informatics

Piero L. Olliaro

University of Oxford - Centre for Tropical Medicine and International Health

Manish Pareek

University of Leicester - Department of Respiratory Sciences

Roberta Piroddi

University of Liverpool - Institute of Population Health Sciences

Riinu Pius

University of Edinburgh - Centre for Medical Informatics

Jonathan M. Read

Lancaster University - Centre for Health Informatics, Computing and Statistics

Clark D. Russell

University of Edinburgh - Queen’s Medical Research Institute

Naveed Sattar

University of Glasgow - Institute of Cardiovascular and Medical Sciences

Catherine A. Shaw

University of Edinburgh - Centre for Medical Informatics

Aziz Sheikh

University of Edinburgh - Asthma UK Centre for Applied Research

Ian P. Sinha

University of Liverpool - Women’s and Children’s Health

Olivia Swann

University of Edinburgh - Department of Child Life and Health

David Taylor-Robinson

University of Liverpool - Institute of Population Health Sciences

Daniel Thomas

Public Health Wales - Communicable Disease Surveillance Centre

Lance Turtle

University of Liverpool - NIHR Health Protection Research Unit for Emerging and Zoonotic Infection

Peter JM Openshaw

Imperial College London - National Heart and Lung Institute

J. Kenneth Baillie

University of Edinburgh - Roslin Institute

Malcolm G. Semple

University of Liverpool - NIHR Health Protection Research Unit for Emerging and Zoonotic Infection

ISARIC4C Investigators

More...

Abstract

Background: Reports of ethnic inequalities in COVID-19 outcomes are conflicting and the reasons for any differences in outcomes are unclear. We investigated ethnic inequalities in critical care admission patterns, the need for invasive mechanical ventilation (IMV), and in-hospital mortality, among hospitalised patients with COVID-19.

Methods: We undertook a prospective cohort study in which dedicated research staff recruited hospitalised patients with suspected/confirmed COVID-19 from 260 hospitals across England, Scotland and Wales, collecting data directly and from records between 6th February and 8th May 2020 with follow-up until 22nd May 2020. Analysis used hierarchical regression models accounting for confounding, competing risks, and clustering of patients in hospitals. Potential mediators for death were explored with a three-way decomposition mediation analysis.

Findings: Of 34,986 patients enrolled, 30,693 (88%) had ethnicity recorded: South Asian (1,388, 5%), East Asian (266, 1%), Black (1,094, 4%), Other Ethnic Minority (2,398, 8%) (collectively Ethnic Minorities), and White groups (25,547, 83%). Ethnic Minorities were younger and more likely to have diabetes (type 1/type 2) but had fewer other comorbidities such as chronic heart disease or dementia than the White group. No difference was seen between ethnic groups in the time from symptom onset to hospital admission, nor in illness severity at admission. Critical care admission was more common in South Asian (odds ratio 1.28, 95% confidence interval 1.09 to 1.52), Black (1.36, 1.14 to 1.62), and Other Ethnic Minority (1.29, 1.13 to 1.47) groups compared to the White group, after adjusting for age, sex and location. This was broadly unchanged after adjustment for deprivation and comorbidities. Patterns were similar for IMV. Higher adjusted mortality was seen in the South Asian (hazard ratio 1.19, 1.05 to 1.36), but not East Asian (1.00, 0.74 to 1.35), Black (1.05, 0.91 to 1.26) or Other Ethnic Minority (0.99, 0.89 to 1.10) groups, compared to the White group. 18% (95% CI, 9% to 56%) of the excess mortality in South Asians was mediated by pre-existing diabetes.

Interpretation: Ethnic Minorities in hospital with COVID-19 were more likely to be admitted to critical care and receive IMV than Whites, despite similar disease severity on admission, similar duration of symptoms, and being younger with fewer comorbidities. South Asians are at greater risk of dying, due at least in part to a higher prevalence of pre-existing diabetes.

Trial Registration: The study was registered at https://www.isrctn.com/ISRCTN66726260.

Funding Statement: This work is supported by grants from: the National Institute for Health Research [award CO-CIN-01], the Medical Research Council [grant MC_PC_19059] and by the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Emerging and Zoonotic Infections at University of Liverpool in partnership with Public Health England (PHE), in collaboration with Liverpool School of Tropical Medicine and the University of Oxford [NIHR award 200907], Wellcome Trust and Department for International Development [215091/Z/18/Z], and the Bill and Melinda Gates Foundation [OPP1209135], and Liverpool Experimental Cancer Medicine Centre for providing infrastructure support for this research (Grant Reference: C18616/A25153). JSN-V-T is seconded to the Department of Health and Social Care, England (DHSC).

Declaration of Interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: AB Docherty reports grants from Department of Health and Social Care, during the conduct of the study; grants from Wellcome Trust, outside the submitted work; CA Green reports grants from DHSC National Institute of Health Research UK, during the conduct of the study; PW Horby reports grants from Wellcome Trust / Department for International Development / Bill and Melinda Gates Foundation, grants from NIHR , during the conduct of the study; JS Nguyen-Van-Tam reports grants from Department of Health and Social Care, England, during the conduct of the study; and is seconded to the Department of Health and Social Care, England (DHSC); PJM Openshaw reports personal fees from consultancies and from European Respiratory Society; grants from MRC, MRC Global Challenge Research Fund, EU, NIHR Biomedical Research Centre, MRC/GSK, Wellcome Trust, NIHR (HPRU in Respiratory Infection), and NIHR Senior Investigator outside the submitted work. His role as President of the British Society for Immunology was unpaid but travel and accommodation at some meetings was provided by the Society. JK Baillie reports grants from Medical Research Council UK; MG Semple reports grants from DHSC National Institute of Health Research UK, grants from Medical Research Council UK, grants from Health Protection Research Unit in Emerging & Zoonotic Infections, University of Liverpool, during the conduct of the study; other from Integrum Scientific LLC, Greensboro, NC, USA, outside the submitted work. EM Harrison, H Ardwick, J Dunning, R Pius, L Norman, KA Holden, JM Read, G Carson, L Merson, J Lee, D Plotkin, L Sigfrid, S Halpin, C Jackson, and C Gamble, all declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; and no other relationships or activities that could appear to have influenced the submitted work.

Ethics Approval Statement: Ethical approval was given by the South Central – Oxford C Research Ethics Committee in England (Ref: 13/SC/0149), and by the Scotland A Research Ethics Committee (Ref: 20/SS/0028).

Suggested Citation

Harrison, Ewen M. and Docherty, Annemarie B. and Barr, Benjamin and Buchan, Iain and Carson, Gail and Drake, Tom M. and Dunning, Jake and Fairfield, Cameron J. and Gamble, Carrol and Green, Christopher A. and Griffiths, Chris and Halpin, Sophie and Hardwick, Hayley E. and Ho, Antonia and Holden, Karl A. and Hollinghurst, Joe and Horby, Peter W. and Jackson, Clare and Katikireddi, Srinivasa Vittal and Knight, Stephen and Lyons, Ronan and MacMahon, James and Mclean, Kenneth A. and Merson, Laura and Murphy, Derek and Nguyen-Van-Tam, Jonathan S. and Norman, Lisa and Olliaro, Piero L. and Pareek, Manish and Piroddi, Roberta and Pius, Riinu and Read, Jonathan M. and Russell, Clark D. and Sattar, Naveed and Shaw, Catherine A. and Sheikh, Aziz and Sinha, Ian P. and Swann, Olivia and Taylor-Robinson, David and Thomas, Daniel and Turtle, Lance and Openshaw, Peter JM and Baillie, J. Kenneth and Semple, Malcolm G. and Investigators, ISARIC4C, Ethnicity and Outcomes from COVID-19: The ISARIC CCP-UK Prospective Observational Cohort Study of Hospitalised Patients (5/31/2020). Available at SSRN: https://ssrn.com/abstract=3618215 or http://dx.doi.org/10.2139/ssrn.3618215

Ewen M. Harrison (Contact Author)

University of Edinburgh - Centre for Medical Informatics ( email )

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Annemarie B. Docherty

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Benjamin Barr

University of Liverpool - Institute of Population Health Sciences

Waterhouse Building, Block B
Brownlow Street
Liverpool, L69 3GL
United Kingdom

Iain Buchan

University of Liverpool ( email )

Chatham Street
Liverpool, L69 7ZA
United Kingdom

University of Manchester ( email )

Oxford Road
Manchester, M13 9PL
United Kingdom

Gail Carson

University of Oxford - Centre for Tropical Medicine and Global Health

United Kingdom

Tom M. Drake

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Jake Dunning

Public Health England - National Infection Service

United Kingdom

Cameron J. Fairfield

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Carrol Gamble

University of Liverpool - Liverpool Clinical Trials Centre

Chatham Street
Liverpool, L69 7ZA
United Kingdom

Christopher A. Green

University of Birmingham - Institute of Microbiology & Infection

Edgbaston, Birmingham B15 2TT
United Kingdom

Chris Griffiths

Queen Mary University of London - Barts and The London School of Medicine and Dentistry

London, EC1M 6BQ
United Kingdom

Sophie Halpin

University of Liverpool - Liverpool Clinical Trials Centre

Chatham Street
Liverpool, L69 7ZA
United Kingdom

Hayley E. Hardwick

University of Liverpool - NIHR Health Protection Research Unit for Emerging and Zoonotic Infection

Antonia Ho

MRC University of Glasgow Centre for Virus Research

Adam Smith Business School
Glasgow, Scotland G12 8LE
United Kingdom

Karl A. Holden

University of Liverpool - Women’s and Children’s Health

Chatham Street
Liverpool, L69 7ZA
United Kingdom

Joe Hollinghurst

Swansea University

Singleton Park
Swansea, Wales SA2 8PP
United Kingdom

Peter W. Horby

University of Oxford - Centre for Tropical Medicine and International Health

Mansfield Road
Oxford, Oxfordshire OX1 4AU
United Kingdom

Clare Jackson

University of Birmingham - Institute of Microbiology & Infection

Edgbaston, Birmingham B15 2TT
United Kingdom

Srinivasa Vittal Katikireddi

MRC/CSO Social & Public Health Sciences Unit, University of Glasgow ( email )

200 Renfield Street
Top floor
Glasgow, Scotland G2 3QB
United Kingdom

Stephen Knight

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Ronan Lyons

University of Swansea ( email )

Singleton Park
Swansea, Wales SA2 8PP
United Kingdom

James MacMahon

Public Health Scotland

No Address Available
United States

Kenneth A. Mclean

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Laura Merson

University of Oxford - ISARIC Global Support Centre

Mansfield Road
Oxford, Oxfordshire OX1 4AU
United Kingdom

Derek Murphy

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Jonathan S. Nguyen-Van-Tam

University of Nottingham - School of Medicine

Nottingham, NG7 2UH
United Kingdom

Lisa Norman

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Piero L. Olliaro

University of Oxford - Centre for Tropical Medicine and International Health

Mansfield Road
Oxford, Oxfordshire OX1 4AU
United Kingdom

Manish Pareek

University of Leicester - Department of Respiratory Sciences

United Kingdom

Roberta Piroddi

University of Liverpool - Institute of Population Health Sciences

Chatham Street
Liverpool, L69 7ZA
United Kingdom

Riinu Pius

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Jonathan M. Read

Lancaster University - Centre for Health Informatics, Computing and Statistics

Lancaster LA1 4YX
United Kingdom

Clark D. Russell

University of Edinburgh - Queen’s Medical Research Institute

Edinburgh
United Kingdom

Naveed Sattar

University of Glasgow - Institute of Cardiovascular and Medical Sciences

Glasgow, Scotland
United Kingdom

Catherine A. Shaw

University of Edinburgh - Centre for Medical Informatics

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Aziz Sheikh

University of Edinburgh - Asthma UK Centre for Applied Research ( email )

Edinburgh
United Kingdom

Ian P. Sinha

University of Liverpool - Women’s and Children’s Health

Chatham Street
Liverpool, L69 7ZA
United Kingdom

Olivia Swann

University of Edinburgh - Department of Child Life and Health

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

David Taylor-Robinson

University of Liverpool - Institute of Population Health Sciences

Waterhouse Building, Block B
Brownlow Street
Liverpool, L69 3GL
United Kingdom

Daniel Thomas

Public Health Wales - Communicable Disease Surveillance Centre

No Address Available
United States

Lance Turtle

University of Liverpool - NIHR Health Protection Research Unit for Emerging and Zoonotic Infection

Peter JM Openshaw

Imperial College London - National Heart and Lung Institute

Guy Scadding Building, Cale Street
London, SW3 6LY
United Kingdom

J. Kenneth Baillie

University of Edinburgh - Roslin Institute

Old College
South Bridge
Edinburgh, Scotland EH8 9JY
United Kingdom

Malcolm G. Semple

University of Liverpool - NIHR Health Protection Research Unit for Emerging and Zoonotic Infection

No contact information is available for ISARIC4C Investigators

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