Higher mortality from COVID-19 in London study in Asian or Black compared to white participants

22 July 2020. Related: COVID-19: pathogenesis, COVID-19.

Simon Collins, HIV i-Base

Research from five leading acute London hospitals in east London, part of the largest NHS Trust, reports significantly worse outcomes from COVID-19 in people from Black, Asian and minority ethnic (BAME) backgrounds.

This important paper, by Vanessa Apea and colleagues reports from a prospective observational majority ethnic diverse (60%) cohort of almost 2000 admission records of confirmed SARS CoV-2 in adults (>16 years). The results are published online, but ahead of peer review. [1]

After excluding 259 records due to lack of ethnicity data, the study included 1737 participants from January to May 2020, 511 of whom had died by day 30 (29%). Overall, 538/1739 (31%) were from Asian, 340 (20%) Black, 156 (7·8%) other and 707 (40%) white backgrounds.

BAME participants were younger (median 64 years for Black and 59 for Asian vs 73 white, p<0.001)) and were less frail with different comorbidity profiles (available for 85%). Being Black or Asian was significantly associated with admission to intensive care and receiving invasive ventilation (OR 1.54; 95% CI: 1.06 to 2.23], p=0.023 and 1.80; 95%CI: 1.20 to 2.71],  p=0.005, respectively). Admission to ICU occurred for 20%, 18% and 11% for Asian, Black and white participants, respectively (p<0.001) although there were no significant differences in use of mechanical ventilation or length of stay in ICU (median 8 to 9 days).

Although a larger proportion of white participants died (33%) overall, after adjusting for age and race, the primary endpoint of mortality by day 30 was significantly higher in Asian (hazard ratio: 1.49; 95%CI: 1.19 to 1.86, p<0.001) and Black (HR: 1.30; 95%CI: 1.02 to 1.63, p=0·036) participants.

After further adjusting for other factors associated with clinical outcomes (including comorbidities, BMI and smoking) the link with mortality persisted in Asian (HR 1.48, CI 1.09 to 2.01, p=0.011) but not in Black (HR 1.32; 95%CI: 0.96 to 1.84, p=0.090) participants. However, in sensitivity analyses, the association with mortality remained for both these groups.

After admission to ICU, being Black and Asian was linked to short time before death compared to white participants: median 6 days (IQR: 3 to 12) and 5 (IQR: 3 to 11) vs 9 (IQR: 4 to 16) respectively, p<0.001.

Also important, acute kidney injury within seven days of admission was highest in Black (35%) participants (vs Asian (22%) and white (24%), p=0.003), who also had higher levels of inflammation (measured by CRP and D-dimer) compared to other ethnicities.

comment

The significant links between race and increased mortality from COVID-19, even after adjusting for comorbidities and socioeconomic factors urgently need further research.

This is likely be a combination of medical, biological and other behavioural/social factors, which are also likely linked to structural ways that related to accessing healthcare in the UK.

The paper itself concludes that the relative contribution of different factors is currently unclear.

Although AIDS was reported as an infrequent comorbidity in five (1.7%) Black and one (0.2%) white participants, it is unclear whether this referred to HIV status or advanced HIV (ie CD4 <200 cells/mm³).

A recent US study also highlighted the disproportionate impact of race in a cohort of 47 HIV positive people with confirmed (n=36) or probable (n=11) COVID-19. Comorbidities were common (85%) but 77% of the COVID-19 cohort were Black and Latinx compared to 40% of the HIV clinic overall. [2]

References

1. Apea VJ et al. Ethnicity and outcomes in patients hospitalised with COVID-19 infection in East London: an observational cohort study. Before peer review. MedRxiv. DOI: 10.1101/2020.06.10.20127621. (12 June 2020).
   https://www.medrxiv.org/content/10.1101/2020.06.10.20127621v1
2. Meyerowitz E et al. Disproportionate burden of COVID-19 among racial minorities and those in congregate settings among a large cohort of people with HIV. AIDS, doi: 10.1097/QAD.0000000000002607.  (25 June 2020).
   https://pubmed.ncbi.nlm.nih.gov/32604138

This report was first posted on 10 July 2020.