Ethnic inequalities in positive SARS-CoV-2 tests, infection prognosis, COVID-19 hospitalisations and deaths: analysis of 2 years of a record linked national cohort study in Scotland

Background This study aims to estimate ethnic inequalities in risk for positive SARS- CoV- 2 tests, COVID- 19 hospitalisations and deaths over time in Scotland.Methods We conducted a population- based cohort study where the 2011 Scottish Census was linked to health records. We included all individuals = 16 years living in Scotland on 1 March 2020. The study period was from 1 March 2020 to 17 April 2022. Self-reported ethnic group was taken from the census and Cox proportional hazard models estimated HRs for positive SARS- CoV- 2 tests, hospitalisations and deaths, adjusted for age, sex and health board. We also conducted separate analyses for each of the four waves of COVID- 19 to assess changes in risk over time.Findings Of the 4 358 339 individuals analysed, 1 093 234 positive SARS- CoV- 2 tests, 37 437 hospitalisations and 14 158 deaths occurred. The risk of COVID- 19 hospitalisation or death among ethnic minority groups was often higher for White Gypsy/ Traveller (HR 2.21, 95% CI (1.61 to 3.06)) and Pakistani 2.09 (1.90 to 2.29) groups compared with the white Scottish group. The risk of COVID- 19 hospitalisation or death following confirmed positive SARS- CoV- 2 test was particularly higher for White Gypsy/Traveller 2.55 (1.81-3.58), Pakistani 1.75 (1.59-1.73) and African 1.61 (1.28-2.03) individuals relative to white Scottish individuals. However, the risk of COVID- 19-related death following hospitalisation did not differ. The risk of COVID- 19 outcomes for ethnic minority groups was higher in the first three waves compared with the fourth wave.Interpretation Most ethnic minority groups were at increased risk of adverse COVID- 19 outcomes in Scotland, especially White Gypsy/Traveller and Pakistani groups. Ethnic inequalities persisted following community infection but not following hospitalisation, suggesting differences in hospital treatment did not substantially contribute to ethnic inequalities.

Automated summary

This study aimed to estimate ethnic inequalities in the risk of positive SARS-CoV-2 tests, COVID-19 hospitalizations, and deaths over time in Scotland. A population-based cohort study linking the 2011 Scottish Census to health records was conducted. The findings revealed that most ethnic minority groups in Scotland, especially White Gypsy/Traveller and Pakistani groups, were at higher risk of adverse COVID-19 outcomes. Ethnic inequalities persisted following community infection but did not exist after hospitalization, suggesting that differences in hospital treatment did not substantially contribute to ethnic inequalities.