Table 2 Summary of the results of included studies

(Abedi et al., 2020) [37]

Ecological study;

US;

369 counties from seven most affected states.

N = 369 counties with 102,178,117 population

Black;

Asian;

Hispanic;

Insurance;

Poverty;

Income;

Education.

COVID-19 infection;

COVID-19 death.

▪ Counties with a higher median income had a higher rate of infection.

▪ A higher percentage of Asians, or Blacks, or Hispanics were associated with a higher rate of infection while a higher percentage of non-Hispanic Whites was associated with a lower rate of COVID-19.

▪ There were no significant associations between percentage of uninsured and risk of COVID-19 infection.

▪ Higher percentage of people under the poverty level (for all the races analyzed in this study), or a higher percentage of people on Medicaid were significantly associated with higher mortality in the counties.

▪ African American population was at higher risk of mortality from COVID-19, conversely, Asians were not.

(Adegunsoye et al., 2020) [33]

Retrospective cohort study;

US;

University of Chicago.

N = 4413 patients tested for COVID-19 from January 1 to April, 15, 2020.

Black (58%)

White (24%)

Other (18%)

Black

Covid-19 infection;

Covid-19 death;

Hospitalization;

Confirmed diagnosis.

▪ Risk of Covid-19 infection in Black race was 3.3 times higher compared to whites.

▪ Risk of Covid-19 hospitalization was 3.8 times higher for Black race compared to whites.

▪ Age-adjusted SARS-CoV-2 positivity rate (0.14) remained higher in Black individuals compared with non-Black individuals (0.19 vs. 0.07).

▪ There were no observed racial differences in mortality among all SARS-CoV-2–positive patients in the entire cohort.

(Adhikari et al., 2020) [32]

Cross-sectional study;

US;

Urban US counties at 10 major us cities with early surges of covid-19 infections.

N = 158 counties

Minority (not specified): categorizing counties as Substantially White, Less diverse, More diverse, and Substantially non-White;

Cumulative incidence (per 100,000);

COVID-19 death

(per 100,000).

▪ In more-poverty counties, those with substantially non-White populations had an infection rate 7.8 times that of counties with substantially White populations and had a death rate 9.3 times greater.

▪ Among both more-poverty and less-poverty counties, those with substantially non-White or more diverse populations had higher expected cumulative COVID-19 incident infections compared with counties with substantially White or less-diverse populations.

▪ Among both more-poverty and less-poverty counties, those with substantially non-White or more diverse populations had higher observed COVID-19 deaths rate.

(Ahmad et al., 2020) [38]

cross sectional ecological study;

US;

3135 US counties.

N = 3135 US counties

Percentage of households in a county with poor housing condition

Incidence rate ratios (per 100,000);

Mortality rate ratios (per 100,000);

▪ In the adjusted models standardized by county population, with each 5% increase in percent households with poor housing conditions, there was a 50% higher risk of COVID-19 incidence and a 42% higher risk of COVID-19 mortality.

(Aldridge et al., 2020) [39]

Prospective cohort study; England

N = 16,272 deaths from COVID-19

Asian (8%)

Black (6%)

Mixed, other (2%)

White (81%)

Minority ethnic group: Black African, Black Caribbean, Pakistani, Bangladeshi and Indian.

COVID-19 death (standardized mortality ratios (SMRs)

▪ Adjusting for region, there was a lower risk of death for White Irish and White British ethnic groups, but increased risk of death for Black African, Black Caribbean, Pakistani, Bangladeshi and Indian minority ethnic groups.

(Azar et al., 2020) [34]

Retrospective cohort study; US;

Sutter Health, a large not-for-profit integrated health

system in northern California.

Group1 N = 14,036 patients

who were tested for COVID-19 from January 1–April 8, 2020

Group2 N = 1052 confirmed cases of COVID-19 By April 8

Non-Hispanic White (89%)

Asian (22%)

African American (12.5%)

American Indian/Pacific Islander (0.9%)

Hispanic (44.9%)

Other (30.8%)

African American;

Household income (median income level by Census ZIP Code Tabulation

Areas (ZCTAs) categorized by quartiles);

Insurance.

COVID-19 testing;

COVID-19 hospitalization

▪ A smaller percentage of African Americans (29.9%) were tested for COVID-19 in an ambulatory setting compared to whites (56.0%), Asians (60.0%), and Hispanics (53.8%) (exhibit 2). The majority of African Americans were tested in hospitals, either in the emergency department (37.8%) or as inpatients (32.3%).

▪ The likelihood of hospital admission for African Americans was 2.7 times higher than that of whites.

▪ People with Medicaid or who were self-pay or had no reported insurance had twice the odds of being admitted, compared to those with commercial insurance.

▪ COVID-19 positive patients residing in ZIP codes within the top two quartiles of income (quartiles 3 and 4) were less likely to be admitted to the hospital than those residing in the bottom quartile ZIP code (OR = 0.24 and 0.55 for the top two quartiles).

(Baqui et al., 2020) [22]

Cross-sectional observational study;

Brazil;

Central-south region (Cs) and north region (n)

N = 11,321 patients withCOVID-19

White (27.8% n; 58.7% Cs)

Pardo (61.5% n; 33.2% Cs)

Black (8.8% n; 6.8% Cs)

East Asian (1.2% n; 1.1% Cs)

Indigenous (0.7% n; 0.3% Cs)

Black

COVID-19 deaths

▪ Compared with White Brazilians, Pardo Brazilians had 45% and Black Brazilians had 58% higher risk of mortality for Covid-19.

(de Lusignan et al., 2020) [27]

Cross-sectional study;

UK

N = 3802 SARS-CoV-2 test results

White (65.7%)

Asian (4.0%)

Black (1.5%)

Mixed, other, unknown (28.8%)

Black;

Urban;

Deprivation.

Confirmed diagnosis

▪ Compared with white people, the adjusted odds of a positive test were 4.75 times greater in black people.

▪ People living in urban areas versus rural areas were 4.59 times more likely to test positive.

▪ People living in more deprived areas were 2.03 times more likely to test positive.

(Drefahl et al., 2020) [40]

Population-based cohort study;

Sweden

N = 7,775,064 individuals with an average follow-up time of 56 days amounting to a total of 1,189,484 person-years under observation.

Lower education;

Lower income;

Immigrants.

COVID-19 deaths

▪ In working ages, those in the lowest income tertile were 5.4 times more likely to die from COVID-19 than those in the highest tertile.

▪ In working ages, those with primary or secondary education were more than twice as likely to die relative to those with postsecondary education.

▪ Immigrants from low and middle-income countries were approximately twice as likely to die, as compared to individuals born in Sweden.

(Egede et al., 2020) [41]

Cross-sectional study;

US;

Milwaukee and

Southeast Wisconsin

N = 31,549 adults tested for

COVID-19 between March 1 and July 10, 2020

Non-Hispanic White (75.4%)

Non-Hispanic Black (19.8%)

Hispanic (4.8%)

Non-Hispanic Black;

Hispanic.

Confirmed diagnosis;

Hospitalization;

COVID-19 death.

▪ In adjusted analyses, Blacks were 3.7 times more likely and Hispanics were 3.1 times more likely to have a positive COVID-19 test compared with Whites.

▪ Among those who had a positive COVID-19 test, members of minority groups (Blacks or Hispanics) were two times more likely to be hospitalized compared with Whites after adjustment for demographics and comorbidities.

▪ After adjustment, compared with Whites, Hispanics were two times more likely to die, and there was a small but statistically nonsignificant difference for Blacks.

(Farrell et al., 2020) [42]

Cross-sectional study;

Ireland;

An Irish hospital

N = 257 patients admitted with a diagnosis of SARS-CoV-2 infection diagnosed between March 13 and May 1, 2020.

White–Irish n = 164 (63.8%)

White–other n = 44 (17.1%)

BAME n = 49 (24.1%)

Non-Irish White;

Black, Asian or minority ethnic (BAME);

Deprivation.

COVID-19 death;

ICU admission.

▪ Deprivation was a strong predictor of mortality, even after adjustment for age, one percentage point increase in deprivation was associated with a 5% increase in mortality.

▪ Patients from care homes were 24% more likely to die than community patients after adjusting for age.

▪ Compared with White Irish people, those of other White or BAME ethnicities did not have an increased risk of hospital death, after adjusting for age. This was also the case when ethnicity was broken down into further subcategories.

▪ After adjusting for age, deprivation was not associated with admittance to ICU.

▪ Compared with White Irish patients, all other ethnic groups including other White or other BAME had an approximately fourfold increased risk of ICU admittance after adjusting for age.

(Goyal et al., 2020) [43]

Cross-sectional study;

US;

An exclusively pediatric drive-through and walk-up SARS-CoV-2 testing site.

N = 1000 children (0 and 22 years) tested for SARS-CoV-2 infection

non-Hispanic (NH)-white (20.3%)

NH-black (30.4%)

Hispanic (22.9%)

Other, unknown (26.4%)

non-Hispanic Black; Hispanic;

Family income;

COVID-19 infection

▪ In comparison with non-Hispanic white children, non-Hispanic Black had 2.3 times higher rates of infection and Hispanic had 6.3 times higher infection.

▪ In comparison with children in the highest median family income quartile, infection rates were 2.6 times higher among children in quartile 3, 2.3 times higher among those in quartile 2, and 2.4 times higher among those in quartile 1.

(Gu et al., 2020) [44]

Retrospective cohort study;

US;

At the University of Michigan.

N = 5698 patients tested or treated for COVID-19 from March 10, 2020, to April 22, 2020.

White (65.6%)

Black (18.6%)

Other, Unknown (15.7%)

Black ethnic group;

Populated living area

Hospitalization;

ICU admission;

COVID-19 death.

▪ Adjusting for age, sex, socioeconomic status, and comorbidity score, Black patients were 72% more likely to be hospitalized compared with White patients.

▪ People living in densely populated areas had 10% higher risk of hospitalization than those non- densely populated areas.

▪ No statistically significant racial differences were found in ICU admission and mortality based on adjusted analysis.

(Hawkins, 2020) [45]

Ecological study;

US;

Massachusetts

N = 87,256 cases of COVID-19 diagnosed in MA between January 1, 2020 and June 10, 2020.

Lower social determinants of health (varia,bles: poverty, Median income, occupations, residents who rented, residents who were uninsured, Unemployment rate)

COVID-19 infection;

COVID-19 testing;

Confirmed diagnosis.

▪ Cities and towns with a higher percentage of residents living in poverty and lower median incomes tended to have elevated rates of COVID-19.

▪ With respect to employment, cities and towns with more workers employed in the healthcare and social assistance and transportation industries and in service and healthcare support occupations also tended to have higher rates of COVID 19.

▪ Communities with a higher proportion of their population renting and uninsured had elevated COVID-19 rates.

▪ Cities and towns with higher levels of poverty, renting, lack of insurance, lower median incomes, andhigher employment in the transportation industry and service and healthcare support occupations tended to have a higher percentage of positive tests.

(Holmes et al., 2020) [46]

Cross-sectional ecologic design;

US;

Selected states based on disparity in the previous epidemics.

N = about five states

% of population

Blacks/AA 13%

Black African American (Black/AA)

Case fatality

▪ Blac/AA had 8% higher risk of death from COVID-19 compared with white population.

(Holtgrave et al., 2020) [47]

Continuum construction;

US;

New York State.

N = 13,990,900 adults 18 years or older of NY

Non-Hispanic white (64%)

Non-Hispanic Black (16%)

Hispanic (19%)

Black non-Hispanic;

Hispanic.

COVID-19 death

Hospitalization;

COVID-19 infection

▪ Compared with white non-Hispanic adults, Black non-Hispanic and Hispanic had approximately doubling risk of infection.

▪ Compared with white non-Hispanic adults, Black non-Hispanics were 4.55 times and Hispanics were 4.36 times at higher risk of hospitalization fro COVID-19.

▪ Compared with white non-Hispanic adults, Black non-Hispanics were 6 times and Hispanics were 4 times at higher risk of death from COVID-19.

(Ioannou et al., 2020) [48]

Longitudinal cohort study;

US;

Department of Veterans Affairs (VA) national health care system.

N = 88,747 patients

tested for SARS-CoV-2 between Feburary 28 and May 14, 2020.

White (49.6%)

Black (41.6%)

Other, unknown (8.9%)

Black ethnicity

Hospitalization;

Mechanical ventilation;

COVID-19 death;

Confirmed diagnosis

▪ Compared with individuals who tested negative, those testing positive were more likely to be Black individuals (19,340 [24.6%] vs 4215 [41.6%]).

▪ Compared with White patients, Black patients were 13% more likely to be hospitalized and 52% more likely to receive mechanical ventilation but no more likely to die from COVID-19.

(Joseph et al., 2020) [49]

Single-institution retrospective cohort study;

US;

Urban quaternary-care academic

medical center with affiliated community health centers.

N = 326 Patients hospitalized with COVID-19 between March 17, 2020, and April 10, 2020.

White (non-Hispanic) n = 116 (35.6%)

Black n = 27 (8%)

Asian n = 10 (3%)

Hispanic n = 142 (43.6%)

Other/unavailable n = 31 (9.5%)

non-White (ie, Hispanic,

Black, Asian, or other)

ICU admission;

COVID-19 death

▪ Among White or non-Hispanic patients (n = 116), 90 (78%) required supplemental oxygen, 36 (31%) were admitted to the intensive care unit, 29 (25%) were intubated, and 27 (23%) died. Among non- White patients (n = 210), 153 (73%) required supplemental oxygen, 83 (40%) were admitted to the intensive care unit, 72 (34%) were intubated, and 19 (9%) died.

(Kabarriti et al., 2020) [50]

Cohort study;

US;

Montefiore Medical Center in New York.

N = 9268 patients tested for COVID-19 between March 14 and April 15, 2020.

Non-Hispanic White (8.6%)

Non-Hispanic Black (32.8%)

Hispanic (32.3%)

Asian, Other, Unknown (26.3%)

Hispanic and non-Hispanic Black

Confirmed diagnosis;

Case fatality rates

▪ Hispanic and non-Hispanic Black patients were approximately 23% and 29%, respectively, more likely to test positive for COVID-19 than White patients.

▪ While controlling for age, sex, socioeconomic status and comorbidities, patients identifying as Hispanic were 23% and non-Hispanic Black were 31% less likely to die compared with non-Hispanic White patients.

(Kaufman et al., 2020) [51]

Cohort study;

US;

All 50 states and the District of Columbia.

N = 2,331,175 patients with positive SARSCoV-

2 NAAT test result.

Black non-Hispanic (12.4%)

Hispanic (22.1%)

White non-Hispanic (56.1%)

Asian, other (9.4%)

Black non-Hispanic community and Hispanic community

Trends of confirmed cases

▪ There was an increasing trend in SARS-CoV-2 NAAT positivity across Black non-Hispanic community progressive quintiles (from 7.8 to 17.2%) and Hispanic community progressive quintiles (from 8.4 to 15.5%) and a decreasing trend across White non-Hispanic community progressive quintiles (from 17.4 to 7.1%).

(Khan et al., 2020) [52]

Prospective cohort study;

England,

Glasgow, and Lanarkshire;

Three acute hospitals.

N = 172 hospitalized patients

with confirmed COVID-19.

Low Socioeconomic status (SES) based on Scottish index for multiple deprivation (SIMD): more deprived (SIMD 1–5) and less deprived (SIMD 6–10)

Need for intubation;

COVID-19 death.

▪ When comparing SIMD 1 to SMID 10, the rate of hospitalization was similar (0.03% vs 0.03%; P = .926).

▪ There is no statistically significant difference in both groups for transfer to critical care, intubation, 30-day all-cause mortality, and overall poor outcome.

(Kim et al., 2020) [53]

Cross-sectional study;

US;

Three hospitals and more than 300 clinics across the Puget Sound.

N = 562,242 patients with at least 1 encounter in the system from January 1, 2019, to February 28, 2020.

non-English speakers (6.0%)

Non-English speakers

Confirmed diagnosis;

Completed testing.

▪ Non-English speakers were overall 16% less likely to have completed testing compared with English-speakers.

▪ Notably, the proportion of positive cases was 4.6-fold higher among non-English speakers overall compared with English speakers.

(Lassale et al., 2020) [54]

Community-based cohort study;

England

N = 428,494 participants from UK biobank.

Ethnic minority groups

Hospitalization

▪ After adjusting for age and sex, compared to the White population, Black individuals had over a 4-fold increased risk of COVID-19 infection (Hospitalization), and there was a doubling of risk in the Asian group and the ‘other’ non-white group.

(Mahajan & Larkins-Pettigrew, 2020) [55]

Correlation analysis;

US;

National

N = 2886 counties

African–Americans;

Asian–Americans

Conformed cases;

COVID-19 Death;

▪ A positive correlation existed between percentages of African–Americans living in a county and who have COVID-19, who have died from COVID-19, and case mortality.

▪ There was also a positive correlation between percentage of Asian–Americans living in a county and percentage who have COVID-19 in that county and percentage who have died from COVID-19 in that county.

▪ There was a negative correlation between percentage of Whites living in a county and percentage who have COVID-19 in that county and percentage who have died from COVID-19 in that county.

(Misa et al., 2020) [56]

Retrospective cohort study;

US;

Northern California

Alameda Health System (AHS).

N = 526 patients tested for COVID-19.

Black (40.7%)

Latinx (26.4%)

White (15.8%)

Asian (7.8%)

Other, Unknown (9.4%)

Latinx;

Black;

Asian

Confirmed diagnosis

▪ Latinx ethnicity had 9.6 times higher likelihood of positive test results compared with non-Latinx patients. In contrast, Black patients had 0.3 times lower risk of positive test results compared with non-Black patients. Asian ethnicity was not associated with odds of confirmed diagnosis.

(Munoz-Price et al., 2020) [57]

Cross-sectional study;

US;

Froedtert Health and Medical College of Wisconsin (Milwaukee).

N = 2595 consecutive adults tested for COVID-19 from March 12 to March 31, 2020.

African American (30.2%)

White (62.3%)

Other (7.4%)

Black;

Poverty status (ie, uninsured or receiving Medicaid)

Confirmed diagnosis;

Hospitalization;

ICU admission;

Mechanical

Ventilation;

COVID-19 death

▪ Regardless of SES, African American patients were 5.37 times more likely to test positive for the virus than persons of other races.

▪ There were no significant associations between poverty status and confirmed diagnosis.

▪ Adjusting for zip code of residence, Black populations were at 1.8 times higher and those with poverty were at 3.8 times higher risk of hospitalization compared with non-Black population and non-poverty status respectively.

ICU admission/ ventilation/ mortality

▪ Poor populations were at 3.6 times higher risk of ICU admission.

▪ There were no statistically significant differences between African American patients and patients from other racial groups in ICU admission among those admitted.

▪ Results for mechanical ventilation and death indicated that neither race nor poverty were significantly associated with these outcomes.

(Niedzwiedz et al., 2020) [58]

prospective cohort

study;

UK;

UK Biobank in

England.

N = 392,116 participants

White (94.7)

South Asian (1.9)

Black (1.6)

Others (1.8)

Black and South Asian;

Deprivation: 4 quartiles

Confirmed diagnosis

▪ Black and south Asian groups were were 3.35 and 2.42, respectively, times more likely to test positive.

▪ Socioeconomic deprivation was associated with a higher risk of confirmed infection so that the most deprived quartile was 2.19 times at higher risk of confirmed infection compared to least deprived quartile.

(Ojinnaka et al., 2020) [59]

Retrospective study;

US;

Texas counties

N = 254 Texas counties

Mean ± SD

% non-Hispanic white 55.4 ± 21.04% Black 6.3 ± 6.40% Asian 1.3 ± 2.08% Hispanic 35.3 ± 22.99

African Americans/ Blacks;

Hispanics;

Unemployment

COVID-19 death (per 100,000)

▪ We observed 5.08 and 4.5% increase in COVID-19 deaths with every 1% increase in the proportion of African Americans/Blacks and Hispanics respectively, but not for Asians.

▪ In addition, there was a 4% increase in COVID-19 deaths/100,000 with every 1% increase in the proportion of unemployed individuals.

(Renelus et al., 2020) [60]

Single-center retrospective cohort study;

US;

New York City (NYC);

university-affiliated NYC hospital.

N = 734 patients with COVID-19

Blacks (50.7%),

Whites (29.2%),

Hispanics (12.5%),

Asians (2.7%)

Others (4.9)

Black;

Hispanics;

Asian.

COVID-19 Hospitalization;

In-hospital mortality.

▪ Blacks were nearly twice as likely as Whites to require hospitalization for COVID-19.

▪ There was no statistically significant difference in odds for COVID-19 hospitalization between Hispanics and Whites.

▪ After adjusting for age and the other variables, Hispanics along with Asians had doubling hazards of in-hospital mortality.

▪ There was a non-significant increased hazard of in-hospital mortality among Blacks when compared with Whites.

(Rentsch et al., 2020) [61]

Retrospective cohort study;

US;

Veterans Affairs.

N = 5,834,543 individuals with at least 1 clinical encounter between January 1, 2018, and December 31, 2019.

White (73.9%)

Black (18.7%)

Hispanic (7.5%)

Black;

Hispanics.

COVID-19 testing;

Confirmed diagnosis;

30-day mortality;

▪ Black individuals were 13% more likely to be tested than Hispanic and 55% higher than whites.

▪ Compared with White populations, Black individuals were 1.9 times more likely and Hispanic individuals were 1.8 times more likely to test positive.

▪ 30-day mortality did not differ by race/ethnicity.

(Rodriguez et al., 2020) [62]

Retrospective data analysis;

US;

88 hospitals in the American Heart Association (AHA) COVID-19 CVD Registry.

N = 8950 patients hospitalized with COVID-19 from 1/17/2020 to 7/22/2020.

non-Hispanic White (59.3%),

Black (10.6%),

Hispanic (all races) (9%),

Asian (4.7%).

Black ethnicity;

Hispanics ethnicity;

Asian ethnicity.

in-hospital mortality;

▪ Compared with non-Hispanic White patients, risks of death from COVID-19 were 7% less for Black patients and 10% less for Hispanic patients, in contrast, and 31% higher for Asian patients.

▪ Although in-hospital mortality and MACE did not differ by race/ethnicity after adjustment, Black and Hispanic patients bore a greater burden of mortality and morbidity due to their disproportionate representation among COVID-19 hospitalizations.

(Sapey et al., 2020) [63]

Retrospective cohort study;

UK;

University Hospitals Birmingham

NHS Foundation Trust (UHB) in Birmingham.

N = 2217 patients with COVID-19

White (69.5)

Mixed/multiple (0.8)

South Asian/South Asian British (18.5) Black/African/Caribbean/black British (6.0)

Other, Unknown (5.2)

Asian;

Black.

COVID-19 death while in hospital or

post discharge

▪ South Asian ethnic populations were at 30% higher risk of death compared with the rest of the population, after adjusting for age, sex, deprivation and comorbidities, and by propensity score matching.

▪ No significant difference was reported in adjusted model for Black ethnic groups.

(Soares et al., 2020) [64]

cohort of SARSCoV-

2–infected patients;

Brazil;

Esp’ırito Santo state.

N = 10,713 patients with COVID-19

White (35%)

Black/multiracial (42.1%)

Asian, indigenous, unknown (22.9%)

Asian ethnic groups;

Black/multiracial groups

COVID-19 hospitalization;

in-hospital COVID-19 death

▪ Asian ethnic groups were at 1.5 times higher risk of hospitalization compared to Withes.

▪ No significant association were found regarding the risk of hospitalization of Black/multiracial groups.

▪ No significant association was found between race/ethnicity of any group and COVID-19 death in hospitalized patients.

(Yehia et al., 2020) [65]

Cohort study; US;

92 hospitals in 12 states.

N = 11,210 adult hospitalized with COVID-19 between February 19, 2020, and May 31, 2020.

White (41%)

Black (37.3%)

With/other/ missing (21.7%)

Black ethnic groups

Insurance

in-hospital COVID-19 death

▪ After adjustment for age, sex, insurance, comorbidities, neighborhood deprivation, and site of care, there was no statistically significant difference in risk of mortality between Black and White patients (hazard ratio, 0.93; 95%CI, 0.80 to 1.09).

▪ Patients with Medicare insurance had 1.5 times, and individuals whose insurance coverage was unknown had 2.2 times higher risk of mortality than those with commercial insurance.

(Zakeri et al., 2020) [66]

Case-control and a cohort study;

UK;

King’s College

Hospital Foundation Trust (KCHFT), which comprises two separate hospitals in south London.

n = consecutive adult patients

(age ≥ 18 years) with COVID-19 requiring emergency hospital admission with a primary diagnosis of, between 1 March and 2 June 2020.

872 cases group; n = 3488 control group.

Black (African, Caribbean, any other Black);

Asian (Indian,

Pakistani, Bangladeshi, Chinese, any other Asian),

COVID-19 hospitalization;

Inhospital mortality

▪ Adjusting for comorbidities and deprivation, Black ethnicity was associated with 2.2 times and Mixed/Other ethnicity was associated with 2.7 times higher admission risk than white ethnicity.

▪ Asian ethnicity was not associated with higher admission risk than whites.

▪ Black ethnicity was not associated with in-hospital mortality.

▪ Asian ethnicity was associated with 1.71 times higher inhospital mortality but with a large confidence interval (1.15–2.56).

(Lieberman-Cribbin et al., 2020) [67]

Retrospective observational study;

US;

New York City (NYC)

177 ZIP code Tabulation

Areas (ZCTA) in NYC

Hispanic;

SES index: household income, gross rent,

poverty, education, working class, unemployed, household density.

Confirmed diagnosis;

The number of total tests

▪ The number of total tests significantly increased with the increasing proportion of white residents but not with increasing Hispanic composition or SES index score.

▪ The ratio of positive tests to total tests significantly decreased with the increasing proportion of white residents in the ZCTA and with increasing SES index score.

(Loomba et al., 2021) [68]

Retrospective study;

US

N = 50 states

Black;

Asian;

Insurance.

COVID-19 death;

Testing frequency;

COVID-19 infection,.

▪ Lower prevalence of uninsured were associated with greater case frequency on univariate analysis.

▪ Lower prevalence of uninsured were associated with greater testing frequency.

▪ Lower prevalence of uninsured were associated with greater percent mortality on univariate linear regression analyses.

▪ No significant association were found between higher frequency of Black or Asian residents and case frequency, testing, and mortality on univariate analysis.

(Ali et al., 2021) [23]

Retrospective cohort study;

Kuwait;

Jaber Al-Ahmad Hospital

N = 405 patients with COVID-19 between February 24 and May 24, 2020.

Arabs (71.6%)

South Asians (28.4%)

South Asians group

ICU admission;

COVID-19 death.

▪ When compared to Arabs, South Asians also had 6.3 times higher odds of being admitted to the ICU.

▪ South Asian patients showed 7.6 times higher odds of dying from COVID-19.

(Ayoubkhani et al., 2020) [69]

Retrospective cohort study; England and

Wales;

Residents of England and Wales enumerated in private households.

N = 47,872,412 residents

White (86.4%)

Bangladeshi and Pakistani (3.0%)

Black (3.2%)

Mixed, other (7.5%)

Black;

Bangladeshi/Pakistani, Indian, Mixed and Other ethnic backgrounds

COVID-19 death (age-standardized mortality rates (ASMRs))

▪ The ASMRs of COVID-19 mortality were greatest among individuals identifying as Black and lowest among those identifying as White.

▪ The rate of COVID-19 death was 3.13 times greater for Black males than for White males, and 2.40 times greater for Black females than White females.

▪ People of Bangladeshi/Pakistani, Indian, Mixed and Other ethnic backgrounds also had raised rates of death involving COVID-19 compared with those of White ethnicity.

(Baena-Diez et al., 2020) [70]

Ecological study;

Spain;

Barcelona.

N = 10 districts of the city of

Barcelona

Poverty (lower income districts)

COVID-19 incidence (per 10,000)

▪ Districts with the lowest mean income had the highest incidence of COVID-19 per 10,000 inhabitants; in contrast, those with the highest income had the lowest incidence.

▪ The district with the lowest income had 2.5 times greater incidence of the disease, compared with the highest-income district.

(Boserup et al., 2020) [71]

cross-sectional study;

US;

48 states/ regions

N = 173 counties

spanning 37 states from

March 1, 2020, to July 11, 2020.

Deprivation;

Unemployment;

English proficiency.

COVID-19 death (per 100,000)

▪ The predicted number of white COVID-19 deaths was 4% higher in counties with an increased percentage of households without a vehicle.

▪ The predicted number of black COVID-19 deaths was 3% higher in counties with an increased percentage of households without a vehicle. Conversely, it was 16% lower in counties with higher unemployment rates.

▪ The predicted number of Hispanic COVID-19 deaths/ 100,000 population was 22% higher in counties with an increased percentage of persons (age ≥ 5 years) who speak English “less than well” and 3% higher in counties with an increased percentage of households with no vehicle available, conversely, was 14% lower in counties with higher unemployment rates.

(DiMaggio et al., 2020) [72]

Ecological study;

US;

New York

N = 177 ZIP code Tabulation

Area (ZCTAs)

Proportion black 0.23

Proportion Hispanic 0.12 (0.05)

Black/African American residents;

Household income;

Housing density;

Non-English proficiency.

Confirmed diagnosis

▪ There was a nearly five-fold increase in the risk of a positive COVID-19 test associated with the proportion of black/African American residents.

▪ For each unit increase in a standardized measure of median household income in a ZCTA, there was an approximately 46% decrease in the number of positive COVID-19 tests.

▪ Increases in the housing density was associated with an approximate doubling of risk.

▪ Proportion of persons not speaking English, and the proportion of persons on public assistance were not associated with positive COVID-19 testing rates.

(Fielding-Miller et al., 2020) [73]

Observational study;

US;

All 50 states

N = 3024 counties from all 50 states

Poverty;

Uninsured;

Non-English;

Language;

Farm worker;

Occupation.

COVID-19 death (per 100,000)

▪ The percentage of non-English speaking households in a county was significantly associated with higher rates of death across all counties.

▪ The percentage of uninsured individuals was associated with fewer reported COVID-19 deaths across all counties.

▪ Poverty was associated with fewer reported deaths across all Mid-Atlantic counties and in non-urban Mid-Atlantic counties, but with more reported deaths in all counties in the East South Central region and in non-urban counties in the same region.

(Figueiredo et al., 2020) [24]

Ecological study;

Brazil

N = all Brazilian Federative Units (FU)

Household income;

Overcrowded households;

Incidence;

COVID-19 death.

▪ Adjusting to lethality and Gini Index of household income, one unit increase in household’s size results in 0.35% increase in risk of COVID-19 infection.

▪ Adjusting for lethality and overcrowded households, one unit increase in the Gini Index of household income results in 0.36% increase in risk of COVID-19 infection.

▪ Adjusting for lethality and Gini Index of household income, one unit increase in household’s size results in 0.35% increase in risk of COVID-19 death.

▪ Adjusting for lethality and overcrowded households, one unit increase in the Gini Index of household income results in 0.41% increase in risk of COVID-19 death.

(Hawkins et al., 2020) [74]

Cohort study;

US;

All 50 states.

N = 3127 counties

Black residents;

Education level;

Unemployment;

Poverty.

Confirmed cases (100,000 population);

Fatality (per 100,000)

▪ The median percentage of black Americans was 4 times higher in severely distressed counties compared with less distressed counties.

▪ The median percentage of uninsured individuals was 49% higher in severely distressed counties compared with less distressed counties.

▪ A higher number of cases were associated with lower education level, higher proportion of black Americans, higher income and lower poverty rate.

▪ Higher COVID-19 mortality was associated with higher income but lower education, higher employment rate, and higher proportion of black Americans.

(Hu et al., 2020)

[75]

Observational study;

US;

city/town level in Massachusetts

N = 6,547,785 people of Massachusetts

Non-Hispanic Black (2.75%)

Hispanic (4.83%)

Asian (3.60%)

Non-Hispanic White (91.06%)

Hispanic

and Non-Hispanic Black/African Americans;

Poverty;

Overcrowding households,

Incidence;

Testing site access

▪ With a parameter estimate of −66.217 (SEM), the rate of the population below the poverty level had a significantly negative influence on the COVID-19 incidence rate.

▪ Income inequality had a nonsignificant and negative impact on the COVID-19 incidence rate.

▪ One-point increase in the rate of households with more than 1 occupant per room was associated with a 157.385-point increase in COVID-19 incidence rate.

▪ Non-Hispanic Black had the lowest weighted travel time of 5.69 min to the testing sites, followed by the Hispanic, Asian, and White groups.

▪ Higher Hispanic and Black/African American segregations are more likely to be associated with a higher COVID-19 incidence rate.

(Madhav et al., 2020) [76]

Observational study;

US;

Neighborhoods in Louisiana.

N = 4138 population (64 parishes (counties)

and 1148 census)

Deprivation (based on Area Deprivation Index (ADI) Quintiles (Q));

Urban.

Rate of COVID-19 infection

▪ The most deprived neighborhoods (5th quintile) had a 30% higher rate of COVID-19 infection compared to those in the least deprived (1st quintile) neighborhoods.

▪ Adjusting for the effect of urban residence, those living in the most deprived neighborhood (5th quintile) had a 39% higher rate of COVID-19 infection compared to those living in the least deprived neighborhood (1st quintile).

▪ Urban location was also significantly associated with COVID-19 infection with 32% higher rate of COVID-19 infection compared to non-urban area.

(Raine et al., 2020) [77]

Cross-sectional study;

US;

National.

US population; 45 out of the 50 US states

White (61.10%)

Latinx (17.80%)

Black (12.30%)

Asian (5.40%)

American Indian or Alaskan Native (AIAN) (0.70%)

Native Hawaiian or Pacific Islander (NHPI) (0.2%)

Other/Unknown (2.6%)

Hispanic/Latinx, American Indian/Alaskan Native, Native Hawaiian/Pacific Islanders, and Black people

Incidence;

COVID-19 death.

▪ On a national level, Hispanic/Latinx, American Indian/Alaskan Native, Native Hawaiian/Pacific Islanders, and Black people had Representation Quotients (RQs) > 1, indicating that these groups are over-represented in COVID-19 incidence.

▪ Dramatic racial and ethnic variances in state-level incidence and mortality RQs were also observed.

(Ossimetha et al., 2021) [78]

Observational study;

US;

Counties with at least one COVID-19 case

N = 2664 counties

Lower social deprivation index (SDI)

COVID-19 infection (per 1000);

COVID-19 death

▪ Medium- and high-SDI counties had 1.39 and 2.56 more SARS-CoV-2 cases/1000 population compared with low-SDI counties, respectively.

▪ Deaths per capita were also significantly higher for higher-SDI counties.

(Khanijahani & Tomassoni, 2021)  [80]

Retrospective observational study;

US;

All 50 states and the District of Columbia

N = 3142 county

Mean (SD)

% Black-concentrated 13.3 (27.2)

Black population (Black-concentrated if 25% or more were Black);

Disadvantaged area

COVID-19 deaths (per 100,000)

▪ For every 10% increase in the percentage of county population residing in concentrated disadvantage and Black-concentrated tracts, the rate for confirmed COVID-19 deaths per 100,000 population increases by a factor of 1.14.

(Khanijahani, 2021)  [79]

Retrospective observational study;

US;

3142 counties in 50 states and the District of Columbia

N = 3142 counties in 50 states and the District of Columbia

Mean (SD)

% Hispanic 9.3 (13.8)

% Black 9.9 (14.7)

Black race;

Hispanic ethnic;

Uninsured residents;

Household size;

Household income; Education

COVID-19 cases;

COVID-19 deaths

▪ 1% increase in proportion of the Hispanic or Black population increase the confirmed cases by 0.68 and 0.69% respectively.

▪ 1% increase in proportion of the Hispanic or Black population increase the COVID-19 death by 0.65 and 1.57%.

▪ Higher proportions of adults with no high school diploma was associated with higher COVID-19 cases (R = 0.32) and deaths (R = 0.37).

▪ One unit higher median household income was associated with 0.89% higher deaths per population unit.

▪ There were no significant association between the average household size and % Uninsured population and confirmed COVID-19 deaths and confirmed COVID-19 cases.

(Weech-Maldonado et al., 2021) [26]

Cross-sectional study;

US;

All US nursing homes.

N = 12,914 nursing home

Minority (not specified): categorizing as high-minority nursing homes and nursing facilities with no minorities.

COVID-1 death

▪ After controlling for interstate differences, facility-level resident characteristics, resource availability, and organizational characteristics, high-minority nursing homes had 61% more COVID-19 deaths as compared to nursing facilities with no minorities.