Health inequalities in risk of SARS-CoV-2 infection in England's second wave: population-based cross-sectional analysis from the REACT-1 study

BMJ Public Health. 2026 Jan 5;4(1):e002596. doi: 10.1136/bmjph-2025-002596. eCollection 2026.

ABSTRACT

OBJECTIVES: The rapid spread of SARS-CoV-2 infection caused high levels of hospitalisation and deaths in late 2020 and early 2021 during the second wave in England. COVID-19 disease during this period was associated with marked health inequalities across ethnic and sociodemographic subgroups. In this paper, we aim to investigate and quantify inequalities in the risk of SARS-CoV-2 infection across ethnic and sociodemographic subgroups during a key period before widespread vaccination, thereby identifying the populations that bore a disproportionate burden of risk.

METHODS: We analysed risk factors for test-positivity for SARS-CoV-2, based on self-administered throat and nose swabs in the community during rounds 5-10 of the REal-time Assessment of Community Transmission-1 (REACT-1) study between 18 September 2020 and 30 March 2021.

RESULTS: Compared with the White ethnicity, people of Asian and the Black ethnicity had a higher risk of infection during rounds 5-10, with odds of 1.45 (1.27, 1.66) and 1.34 (1.11, 1.63), respectively, adjusted for demographic factors including age, sex, region, key work status, ethnicity and deprivation. Among ethnic subgroups, the highest and the second-highest odds were found in Bangladeshi and Pakistani participants at 3.28 (2.24, 4.80) and 2.12 (1.70, 2.64), respectively, when compared with the White British participants. People in larger (compared with smaller) households had higher odds of infection. Healthcare workers with direct patient contact and care home workers showed higher odds of infection compared with other essential/key workers. Additionally, the odds of infection among participants in public-facing activities or settings were greater than among those not working in those activities or settings.

CONCLUSION: Our findings highlight the differences in the risk of SARS-CoV-2 infection in a global north population during a period when the risk of infection was high, and there were substantial levels of social mixing. Planning for future waves of severe respiratory pathogens should include policies to reduce inequality in the risk of infection by ethnicity, household size and occupational activity in order to reduce inequality in disease.

PMID:42877679 | PMC:PMC13663695 | DOI:10.1136/bmjph-2025-002596