Ethnic inequalities in COVID-19 infection, hospitalisation, intensive care admission, and death: a global systematic review and meta-analysis of over 200 million study participants


COVID-19 has exacerbated existing ethnic inequalities in health. Little is known about whether inequalities in severe disease and deaths, observed globally among minoritised ethnic groups, relates to greater infection risk, poorer prognosis, or both. We analysed global data on COVID-19 clinical outcomes examining inequalities between people from minoritised ethnic groups compared to the ethnic majority group.


Databases (MEDLINE, EMBASE, EMCARE, CINAHL, Cochrane Library) were searched from 1st December 2019 to 3rd October 2022, for studies reporting original clinical data for COVID-19 outcomes disaggregated by ethnicity: infection, hospitalisation, intensive care unit (ICU) admission, and mortality. We assessed inequalities in incidence and prognosis using random-effects meta-analyses, with Grading of Recommendations Assessment, Development, and Evaluation (GRADE) use to assess certainty of findings. Meta-regressions explored the impact of region and time-frame (vaccine roll-out) on heterogeneity. PROSPERO: CRD42021284981.


77 studies comprising over 200,000,000 participants were included. Compared with White majority populations, we observed an increased risk of testing positive for infection for people from Black (adjusted Risk Ratio [aRR]:1.78, 95% CI:1.59–1.99, I2 = 99.1), South Asian (aRR:3.00, 95% CI:1.59–5.66, I2 = 99.1), Mixed (aRR:1.64, 95% CI:1.02–1.67, I2 = 93.2) and Other ethnic groups (aRR:1.36, 95% CI:1.01–1.82, I2 = 85.6). Black, Hispanic, and South Asian people were more likely to be seropositive. Among population-based studies, Black and Hispanic ethnic groups and Indigenous peoples had an increased risk of hospitalisation; Black, Hispanic, South Asian, East Asian and Mixed ethnic groups and Indigenous peoples had an increased risk of ICU admission. Mortality risk was increased for Hispanic, Mixed, and Indigenous groups. Smaller differences were seen for prognosis following infection. Following hospitalisation, South Asian, East Asian, Black and Mixed ethnic groups had an increased risk of ICU admission, and mortality risk was greater in Mixed ethnic groups. Certainty of evidence ranged from very low to moderate.


Our study suggests that systematic ethnic inequalities in COVID-19 health outcomes exist, with large differences in exposure risk and some differences in prognosis following hospitalisation. Response and recovery interventions must focus on tackling drivers of ethnic inequalities which increase exposure risk and vulnerabilities to severe disease, including structural racism and racial discrimination.

Author list



  1. School of Social Sciences, University of Manchester, United Kingdom
  2. Department of Respiratory Sciences, University of Leicester, United Kingdom
  3. Department of Infection and HIV Medicine, University Hospitals Leicester NHS Trust, United Kingdom
  4. Li Ka Shing Centre for Health Information and Discovery, Oxford Big Data Institute, University of Oxford, United Kingdom
  5. NIHR Leicester Biomedical Research Centre, United Kingdom
  6. Department of Global Health and Social Medicine, King’s College London, United Kingdom
  7. Department of Cardiovascular Sciences, University of Leicester, United Kingdom
  8. MRC/CSO Social & Public Health Sciences Unit, University of Glasgow, United Kingdom
  9. University Hospitals of Leicester, Education Centre Library, Glenfield Hospital and Leicester Royal Infirmary, United Kingdom 
  10. Department of Health Sciences, University of Leicester, United Kingdom
  11. Division of Epidemiology and Public Health, School of Medicine, University of Nottingham, United Kingdom


Patricia Irizar1,∗ Daniel Pan,2,3,4,5 Dharmi Kapadia,1 Laia Bécares,6 Shirley Sze,7 Harry Taylor,1 Sarah Amele,Eliud Kibuchi,8 Pip Divall,9Laura J. Gray,10 Laura B. Nellums,11 Srinivasa Vittal Katikireddi,8 and Manish Pareek2,3,5

Novel Coronavirus SARS-CoV-2


e Clinical Medicine