Background COVID-19 vaccine uptake is lower amongst most minority ethnic groups compared to the White British group in England, despite higher COVID-19 mortality rates. Here, we add to existing evidence by estimating inequalities for 16 minority ethnic groups, examining ethnic inequalities within population subgroups, and comparing the magnitudes of ethnic inequalities in COVID-19 vaccine uptake to those for routine seasonal influenza vaccine uptake. Methods and findings We conducted a retrospective cohort study using the Greater Manchester Care Record, which contains de-identified electronic health record data for the population of Greater Manchester, England. We used Cox proportional hazards models to estimate ethnic inequalities in time to COVID-19 vaccination amongst people eligible for vaccination on health or age (50+ years) criteria between 1 December 2020 and 18 April 2021 (138 days of follow-up). We included vaccination with any approved COVID-19 vaccine, and analysed first-dose vaccination only. We compared inequalities between COVID-19 and influenza vaccine uptake adjusting by age group and clinical risk, and used subgroup analysis to identify populations where inequalities were widest. The majority of individuals (871,231; 79.24%) were White British. The largest minority ethnic groups were Pakistani (50,268; 4.75%), ‘other White background’ (43,195; 3.93%), ‘other ethnic group’ (34,568; 3.14%), and Black African (18,802; 1.71%). In total, 83.64% (919,636/1,099,503) of eligible individuals received a COVID-19 vaccine. Uptake was lower compared to the White British group for 15 of 16 minority ethnic groups, with particularly wide inequalities amongst the groups ‘other Black background’ (hazard ratio [HR] 0.42, 95% CI 0.40 to 0.44), Black African (HR 0.43, 95% CI 0.42 to 0.44), Arab (HR 0.43, 95% CI 0.40 to 0.48), and Black Caribbean (HR 0.43, 95% CI 0.42 to 0.45). In total, 55.71% (419,314/752,715) of eligible individuals took up influenza vaccination. Compared to the White British group, inequalities in influenza vaccine uptake were widest amongst the groups ‘White and Black Caribbean’ (HR 0.63, 95% CI 0.58 to 0.68) and ‘White and Black African’ (HR 0.67, 95% CI 0.63 to 0.72). In contrast, uptake was slightly higher than the White British group amongst the groups ‘other ethnic group’ (HR 1.11, 95% CI 1.09 to 1.12) and Bangladeshi (HR 1.08, 95% CI 1.05 to 1.11). Overall, ethnic inequalities in vaccine uptake were wider for COVID-19 than influenza vaccination for 15 of 16 minority ethnic groups. COVID-19 vaccine uptake inequalities also existed amongst individuals who previously took up influenza vaccination. Ethnic inequalities in COVID-19 vaccine uptake were concentrated amongst older and extremely clinically vulnerable adults, and the most income-deprived. A limitation of this study is the focus on uptake of the first dose of COVID-19 vaccination, rather than full COVID-19 vaccination. Conclusions Ethnic inequalities in COVID-19 vaccine uptake exceeded those for influenza vaccine uptake, existed amongst those recently vaccinated against influenza, and were widest amongst those with greatest COVID-19 risk. This suggests the COVID-19 vaccination programme has created additional and different inequalities beyond pre-existing health inequalities. We suggest that further research and policy action is needed to understand and remove barriers to vaccine uptake, and to build trust and confidence amongst minority ethnic communities. Ruth Elizabeth Watkinson and colleagues estimate inequalities in Covid-19 vaccine uptake for 16 minority ethnic groups and compare them to those in routine seasonal Influenza vaccine uptake. Author summary Why was this study done? Previous research has found wide disparities in early COVID-19 vaccine uptake between ethnic groups in many countries. Uptake of COVID-19 vaccination was particularly low amongst older adults belonging to Black or Black British ethnic groups in the UK. However, previous research has tended to use broad ethnic groupings, and ethnic inequalities in COVID-19 vaccination uptake had not been contextualised by comparison with inequalities in uptake of previous vaccination programmes. What did the researchers do and find? We used electronic health records for the population of Greater Manchester, England, to estimate inequalities in COVID-19 and seasonal influenza vaccine uptake between the White British group and 16 minority ethnic groups. We found that ethnic inequalities in COVID-19 vaccine uptake are far wider than those seen previously for seasonal influenza vaccine uptake, and exist even amongst those recently vaccinated against influenza. Ethnic inequalities in COVID-19 vaccine uptake are concentrated amongst the most vulnerable—those living in the most deprived neighbourhoods, and older and extremely clinically vulnerable adults. What do these findings mean? These findings suggest that the COVID-19 vaccine rollout has exacerbated pre-existing health inequalities in vaccine uptake. Themes raised in our public and community discussion groups suggest that both lower trust in COVID-19 vaccines and practical barriers to vaccine access likely contribute to lower COVID-19 vaccine uptake amongst minority ethnic groups. Further research and community engagement is needed to build trust and confidence amongst minority ethnic communities, and to better understand and remove barriers to vaccine access.
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