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Ethnic disparities in COVID-19 outcomes: a multinational cohort study of 20 million individuals from England and Canada

Zaccardi, Francesco; Tan, Pui San; Shah, Baiju R.; Everett, Karl; Clift, Ash Kieran; Patone, Martina; Saatci, Defne; Coupland, Carol; Griffin, Simon J.; Khunti, Kamlesh; Dambha-Miller, Hajira; Hippisley-Cox, Julia

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Francesco Zaccardi

Pui San Tan

Baiju R. Shah

Karl Everett

Ash Kieran Clift

Martina Patone

Defne Saatci

Professor of Medical Statistics

Simon J. Griffin

Kamlesh Khunti

Hajira Dambha-Miller

Julia Hippisley-Cox


Background: Heterogeneous studies have demonstrated ethnic inequalities in the risk of SARS-CoV-2 infection and adverse COVID-19 outcomes. This study evaluates the association between ethnicity and COVID-19 outcomes in two large population-based cohorts from England and Canada and investigates potential explanatory factors for ethnic patterning of severe outcomes. Methods: We identified adults aged 18 to 99 years in the QResearch primary care (England) and Ontario (Canada) healthcare administrative population-based datasets (start of follow-up: 24th and 25th Jan 2020 in England and Canada, respectively; end of follow-up: 31st Oct and 30th Sept 2020, respectively). We harmonised the definitions and the design of two cohorts to investigate associations between ethnicity and COVID-19-related death, hospitalisation, and intensive care (ICU) admission, adjusted for confounders, and combined the estimates obtained from survival analyses. We calculated the ‘percentage of excess risk mediated’ by these risk factors in the QResearch cohort. Results: There were 9.83 million adults in the QResearch cohort (11,597 deaths; 21,917 hospitalisations; 2932 ICU admissions) and 10.27 million adults in the Ontario cohort (951 deaths; 5132 hospitalisations; 1191 ICU admissions). Compared to the general population, pooled random-effects estimates showed that South Asian ethnicity was associated with an increased risk of COVID-19 death (hazard ratio: 1.63, 95% CI: 1.09-2.44), hospitalisation (1.53; 1.32-1.76), and ICU admission (1.67; 1.23-2.28). Associations with ethnic groups were consistent across levels of deprivation. In QResearch, sociodemographic, lifestyle, and clinical factors accounted for 42.9% (South Asian) and 39.4% (Black) of the excess risk of COVID-19 death. Conclusion: International population-level analyses demonstrate clear ethnic inequalities in COVID-19 risks. Policymakers should be cognisant of the increased risks in some ethnic populations and design equitable health policy as the pandemic continues.


Zaccardi, F., Tan, P. S., Shah, B. R., Everett, K., Clift, A. K., Patone, M., …Hippisley-Cox, J. (2023). Ethnic disparities in COVID-19 outcomes: a multinational cohort study of 20 million individuals from England and Canada. BMC Public Health, 23(1), Article 399.

Journal Article Type Article
Acceptance Date Feb 6, 2023
Online Publication Date Feb 27, 2023
Publication Date Feb 27, 2023
Deposit Date Mar 2, 2023
Publicly Available Date Mar 2, 2023
Journal BMC Public Health
Electronic ISSN 1471-2458
Publisher Springer Science and Business Media LLC
Peer Reviewed Peer Reviewed
Volume 23
Issue 1
Article Number 399
Keywords Ethnicity, COVID-19, Mortality, Hospitalisation, UK, Canada, Inequalities
Public URL
Publisher URL
Additional Information Received: 10 March 2022; Accepted: 6 February 2023; First Online: 27 February 2023.