Incidence and severe outcomes from COVID-19 among immigrant and minority ethnic groups and among groups of different socio-economic status: A systematic review
Systematic review
|Published
In this systematic review we have summarised and assessed available research from Norway and countries with similar welfare systems on the incidence of infection, rate of admission to hospital and death due to COVID-19. Populations of special interest were immigrants and minority ethnic groups as well as people with different socio-economic status.
Key message
In this systematic review we have summarised and assessed available research from Norway and countries with similar welfare systems on the incidence of infection, rate of admission to hospital and death due to COVID-19. Populations of special interest were immigrants and minority ethnic groups as well as people with different socio-economic status. We included two studies from Norway (data up to November 2020), one study from Denmark (data up to September 2020) and nine studies from Sweden (data mainly up to May 2020).
In Norway, the highest risk of COVID-19 infection (measured as Relative Risk Increase (RRI)), was among people born in Somalia, Pakistan, Iraq, Afghanistan and Turkey. In Denmark, the highest RRI of COVID-19 was among people born in Somalia, Pakistan, Morocco, Lebanon and Turkey. In Sweden, among people born in Turkey, Ethiopia, Somalia, Chile and Iraq.
The occupational groups with the highest proportion of COVID-19 cases were different in the different waves of the pandemic. In the first wave in Norway, it was healthcare workers and drivers and in the second wave restaurant staff and tourist guides. In almost all occupational groups in Denmark, the proportion of COVID-19 infection was higher among people with non-Western origin than among people with Western and Danish origin.
COVID-19 related admission to hospital occurred more often among people with non-Western origin in Norway and Denmark compared to those with Norwegian and Danish origin. In Sweden the risk for admission to hospital was higher for people who were not employed, for those who had to be present at work at least 50% of the time, and for people working in the health care system compared to those working from home.
The number of COVID-19 related deaths in Norway and Denmark was too low to conclude about variation by country of birth. In Sweden, the results indicated that the risk of dying from COVID -19 was higher among people born in Low- or Middle-Income Countries compared to Swedish born. Also, a low socio-economic position, measured by education and net income, predicted an increased risk of death from COVID-19.
Summary
Background
The current COVID-19 pandemic is affecting the whole world, including the population of Norway. There have been reports that belonging to certain minority ethnic groups and groups of low socio-economic status may increase the risk of infection and severe outcome from COVID-19.
Objective
In this systematic review we have summarised and assessed available research from Norway and countries with similar welfare systems on the incidence of COVID-19 infection, rate of admission to hospital and death during the COVID-19 pandemic. Populations of special interest were immigrants and minority ethnic group as well as people with different socioeconomic status.
Method
Our inclusion criteria were: Population: Minority ethnic groups, populations with different socio-economic status, people living in deprived areas. Exposure: The COVID-19 pandemic. Comparison: No limitation. Outcome: Incidence of COVID-19, admission to hospital for COVID-19, admission to intensive care unit for COVID-19, need for use of ventilator for COVID-19, mortality for COVID-19. Study design: Systematic reviews and primary studies. Setting: Our analysis included studies conducted in Norway and other similar Nordic welfare states: Denmark, Finland, Iceland and Sweden. We also included studies from countries with welfare systems closely resembling the Nordic model: Austria, Belgium, the Netherlands and New Zealand. Studies from countries with welfare systems with some features resembling the Nordic model was presented in tables: Australia, Germany, Great Britain and Ireland. Literature search: We searched for relevant literature in the End-Note database for the NIPH live map of COVID-19 evidence on November 30th 2020, and for grey literature in selected web pages in Norway, Denmark, Finland, Iceland and Sweden on December 10th 2020. Inclusion of studies were performed according to the PRISMA-rules. Due to heterogeneity in time frame of sampling, the difference in covariates adjusted for in different studies, and variation in infection, prevention and control measures implemented in the different countries, we did not consider it appropriate to conduct meta-analysis. Results are presented narratively. We used the GRADE-approach for assessing our confidence in the evidence.
Results
We included 64 publications (from 7675 identified) in this systematic review. For countries with welfare systems closely resembling the Norwegian, we included one study from Denmark (data up to September 2020) and nine from Sweden (data mainly up to May 2020) in addition to two studies from Norway (data up to November 2020). Results were reported differently, therefore we report both common features and from each country.
The studies from the Scandinavian countries provided analysis based on country of birth. In Norway, the highest risk of COVID-19 infection (measured as Relative Risk Increase (RRI)), was among people born in Somalia (780%), Pakistan (711%), Iraq (494%), Afghanistan (427%) and Turkey (395%). In Denmark, the highest RRI of COVID-19 was among people born in Somalia (1191%), Pakistan (899%), Morocco (603%), Lebanon (404%) and Turkey (306%). In Sweden, the RRI was highest among people born in Turkey (298%), Ethiopia (293%), Somalia (249%), Chile (230%) and Iraq (217%).
In Norway, the occupational groups with highest incidence of COVID-19 infections during the first wave of the pandemic were health care workers and drivers of busses, trams and taxies. In the second wave it was restaurant staff and tourist guides. In Denmark, the incidence of COVID-19 infection was reported by occupational group and origin combined. The occupations with the highest total number of cases per 100 000 were as follows: health and social services: 874 (for non-Western: 1931, Western: 1093 and Danish origin: 772), public administration, defence and police: 468 (non-Western 2115, Western: 1043 and Danish origin: 395), and transport: 436 (non-Western 1815, Western 405, and Danish origin: 238). In almost all occupational groups the proportion of COVID-19 infection was higher among people with non-Western origin than among people with Western and Danish origin. The occupational group with both the highest (absolute) numbers of non-Western employees and COVID-19 cases, was health and social services. Furthermore, non-western transport workers had more than seven times higher infection rate compared to Danish transport workers, and thus represented the largest relative difference.
In Norway and Denmark, COVID-19 related rate of admissions to hospital occurred more often among people with non-Western origin compared to those with Norwegian and Danish origin, respectively. In Norway, the number per 100 000 was significantly higher among people born in Pakistan (510), followed by Somalia (424), and Turkey (235) compared to Norwegian born (27). In Denmark, people of non-Western origin comprise 8.9% of the population, but 15.3% of the COVID-19 related hospital admissions. This is 1.7 times higher compared to people of Danish origin In Stockholm (not reported for Sweden as a whole), the risk for admission to hospital was higher for people who were not employed (Hazard Ratio (HR) 1.25 [95% CI 1.12 to 1.38]), for those who had to be present at work at least 50% of the time (HR 1.24 [95% CI 1.12 to 1.36]), and for people working in the health care system (HR 1.68 [95% CI 1.47 to 1.92]) compared to those working from home (adjusted for sex, age, country of birth, living area and education).
The number of COVID-19 related deaths in Norway and Denmark was too low to conclude about variation by country of birth, but it may seem that there is a higher proportion of deaths for people born in Africa and Asia than for people born in Norway. In Sweden, the results indicated that the risk of dying from COVID -19 was higher among people born in Low- or Middle-Income Countries compared to Swedish born (HRmen: 2.20 [95% CI 1.81 to 2.69] and HRwomen: 1.66 [95% CI 1.32 to 2.09]). Also, low socioeconomic position, measured by education and net income, predicted an increased risk of death from COVID-19.
Discussion
The included epidemiological studies were well conducted and generally based on reliable data information sources. However, the studies for the different countries covered different follow-up periods, and the variation in infection, prevention and control measures implemented in the different countries means that the results are not directly comparable.
Incidence of COVID-19 infection were reported by country of birth in Norway, Sweden and Denmark. However, the incidence, admission to hospital and death of COVID-19 in different socio-economic groups measured by education and income was only reported for Sweden.
A strength with systematic reviews is the systematic and transparent approach used when conducting it. An inherent challenge with systematic reviews is that they may be out of date as soon as the literature search is completed, because new studies are continuously being published. For the question in this systematic review, we are aware of three new publications from Norway after our literature search. All of them confirm the results presented in this systematic review.
The theme of this review pertain to an ongoing pandemic, and there is a need for more research of good quality on many aspects of this pandemic. Especially there is a need for knowledge about targeted interventions to reduce the high incidence of infection and disease in minority ethnic groups and groups with low socioeconomic status.
Conclusion
The Scandinavian studies report an increased risk of being infected and admitted to hospital due to COVID-19 for several minority ethnic groups. The groups with the highest rates were by and large overlapping across Scandinavia. It was also found a higher risk for COVID-19 related mortality among minority ethnic groups in Sweden, whereas mortality data for Norway and Denmark was too sparse to conclude.
Furthermore, in Denmark, the proportion of COVID-19 infection was higher among people of non-Western origin than among people of Western and Danish origin in almost all occupational groups. Incidence of COVID-19 infection was not reported by education and income in Norway and Denmark, whereas for Sweden the results were unclear. However, analyses of Swedish data show that admission to hospital and death occurred more frequently in groups of lower socio-economic status.
