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Background: The relationship between ethnicity and COVID-19 is uncertain. We performed a systematic review to assess whether ethnicity has been reported in patients with COVID-19 and its relation to clinical outcomes. Methods: We searched EMBASE, MEDLINE, Cochrane Library and PROSPERO for English-language citations on ethnicity and COVID-19 (1 st December 2019-15 th May 2020). We also reviewed: COVID-19 articles in NEJM, Lancet, BMJ, JAMA, clinical trial protocols, grey literature, surveillance data and preprint articles on COVID-19 in MedRxiv to evaluate if the association between ethnicity and clinical outcomes were reported and what they showed. PROSPERO:180654. Findings: Of 207 articles in the database search, five reported ethnicity; two reported no association between ethnicity and mortality. Of 690 articles identified from medical journals, 12 reported ethnicity; three reported no association between ethnicity and mortality. Of 209 preprints, 34 reported ethnicity À 13 found Black, Asian and Minority Ethnic (BAME) individuals had an increased risk of infection with SARS-CoV-2 and 12 reported worse clinical outcomes, including ITU admission and mortality, in BAME patients compared to White patients. Of 12 grey literature reports, seven with original data reported poorer clinical outcomes in BAME groups compared to White groups. Interpretation: Data on ethnicity in patients with COVID-19 in the published medical literature remains limited. However, emerging data from the grey literature and preprint articles suggest BAME individuals are at an increased risk of acquiring SARS-CoV-2 infection compared to White individuals and also worse clinical outcomes from COVID-19. Further work on the role of ethnicity in the current pandemic is of urgent public health importance.

Importance The association of ethnicity with outcomes in patients with COVID-19 is unclear. Objective To determine whether the risk of SARS-CoV-2 infection, COVID-19 intensive care unit (ICU) admission and mortality are associated with ethnicity. Data Sources We searched all English language articles published 1st December 2019 - 30th June 2020 within MEDLINE, EMBASE, PROSPERO and the Cochrane library using indexing terms for COVID-19 and ethnicity, as well as manuscripts awaiting peer review on MedRxiv during the same period. Study Selection Included studies reported original clinical data, disaggregated by ethnicity, on patients with confirmed or suspected COVID-19. We excluded correspondence, area level, modelling and basic science articles. Two independent reviewers screened articles for inclusion. Of 926 identified articles, 35 were included in the meta-analyses. Data Extraction and Synthesis The review was conducted according to PRISMA guidelines. Reviewers independently extracted data using a piloted form on: (1) rates of infection, ICU admission and mortality by ethnicity; and (2) unadjusted and adjusted data comparing ethnic minority and White groups. Data were pooled using random effects models. Main Outcomes and Measures Outcomes were: (1) infection with SARS-CoV-2 confirmed on molecular testing; (2) ICU admission; and (3) mortality in COVID-19 confirmed and suspected cases. Results 13,535,562 patients from 35 studies were included in the meta-analyses. Black, Asian and Hispanic individuals had a greater risk of infection compared to White individuals (Black: pooled adjusted RR: 2.06, 95% CI: 1.59-2.67; Asian: 1.35, 95%CI: 1.15-1.59; Hispanic: 1.77, 95% CI: 1.39-2.25). Black individuals were significantly more likely to be admitted to ICU than White individuals (pooled adjusted RR: 1.61, 95% CI: 1.02-2.55). Risk of mortality was similar across ethnicities among hospitalised patients, but increased among Asian and Mixed ethnic groups in the general population. Conclusions Black, Asian and Hispanic ethnic groups are at increased risk of SARS-CoV-2 infection. Black individuals may be more likely to require ICU admission for COVID-19. There may also be disparities in risk of death from COVID-19 at a population level. Our findings are of critical public health importance and should inform policy on minimising SARS-CoV-2 exposure in ethnic minority groups.