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.