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Comment by lettergram | Hacker News Reader

I think one of the key takeaways is in the abstract:

> People from Asian and black groups are at markedly increased risk of in-hospital death from COVID-19, and contrary to some prior speculation is only partially attributable to pre-existing clinical risk factors or deprivation

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Deprivation equals poverty.

Asian in Britain will primarily be Indian/Pakistani descent.

I wonder if this is vitamin d related? Darker complexion of black and Asian could cause higher risks of vitamin d deficiency in UK.

Very likely it explains at least part of the difference.

Because obviously people with darker skins produce less vitamin D naturally and are more vitamin D deficient and all indications are that vitamin D deficiency is a big factor in Covid19 morality.

Could be dietary related too, or factors relating to multiple generations of families cohabiting. That said, these are prevalent in the sunny parts of Asia too, which doesn’t appear to be suffering so much, so my suspicion would be Vit-D related.

South Asians and East Asians are pretty different genetically, so the lack of distinction really doesn't help.

In the UK Asian == South Asian

Source? I've never got that impression as an English person. I consider it to be non-specific. However, if you're in a place like Southall or Bradford then the "Asian" people around you are indeed more likely to be south Asian.

https://en.wikipedia.org/wiki/British_Asian

https://webarchive.nationalarchives.gov.uk/20160106185816/ht...

> Asian/Asian British

> 9. Indian

> 10. Pakistani

> 11. Bangladeshi

> 12. Chinese

> 13. Any other Asian background, please describe

But Indian/Pakistani aren't dying at much higher rate in their own country or are they? I've no data.

I would imagine that the sun is hotter and shows itself more often in India and Pakistan - hence the darker complexion.

Much easier to have a vitamin D deficiency in Britain than in India/Pakistan because there is so much less sun.

It seems pretty remarkable that men have a hazard factor 2x that of women as well.

There was a post on HN a few days ago about a study that found low testosterone levels were correlated with worse Covid-19 outcomes. I think vitamin D is technically a hormone (or maybe is hormone-like?) so I wonder if it’s absorbed differently by men than women. Or maybe low testosterone is just a side effect of a vitamin D deficiency in men.

It could also be low levels of sex hormones in general - having neither estrogen nor testosterone in your body causes osteoporosis, for example. Excess testosterone is metabolized into estrogen, as well.

But the endocrine system is ferociously complex - maybe endocrine abnormalities are a proxy for obesity, or an underlying thyroid issue etc.

According to [0], vitamin D deficiency is associated with higher free testosterone in men and lower estradiol in women. Higher testosterone is associated with cardiovascular problems, which are a big COVID risk factor.

But that doesn't jib well with the study you find, so I dunno what to make of it.

0. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5218632/#__ffn_...

One study suggested that progesterone was a factor in reducing viral levels.

I think that low testosterone levels is correlated with being older which is correlated with worse Covid-19 outcomes, so age is the important factor here.

Men also might have other factors compared to women. As an example 2x as many men vs women die in auto accidents.

I was surprised to hear that figure! I did my own research and it appears to be correct (in fact, it's greater than 2x in recent years). However, that ratio ignores vehicle miles driven. Once you account for that, the comparative ratio is slightly lower:

https://www.iihs.org/topics/fatality-statistics/detail/gende...

> The number of driver fatal crash involvements per 100 million miles driven in 2017 was 62 percent higher for males (2.1 per 100 million miles traveled) than for females (1.3 per 100 million miles traveled). Rates were substantially higher for males than for females ages 16-29, but were only slightly higher for ages 30 and older. The gender difference was largest among drivers ages 20-29.

So in some sense the real figure is 1.62x for men as women per mile driven, although (1) men driving more miles is still a real thing and as a result more men die, and (2) I don't know to what extent super-distance drivers (like commercial truck drivers, who skew heavily male) are putting their finger on the scale.

If you ignore teenagers, that difference comes out to 1.59x; and leaving out persons <30, 1.46x. Still much higher than 1.0.

Women have a more "advanced" immune system, since many of the genes involved in the immune system are located on the X chromosome. The downside of this is that women are also more at risk of auto-immune disease.

https://www.nature.com/articles/nri2815?proof=true

Important to note that in UK parlance, "asian" usually encompasses middle-eastern and (I think) Indian ethnicities, whereas in the US is doesn't.

This distinction might be important if there is some sort of vitamin-D/skin-melanin correlation to outcomes in northern latitudes.

>> is only partially attributable to pre-existing clinical risk factors or deprivation

I'd expect more it is attributable to less access to premium healthcare (remember, in the UK everyone gets healthcare, but not everyone gets privately-sponsored add-on healthcare)

UK privately-sponsored healthcare specialises in things that you cannot get free from the National Health Service or things where the wait time is long - for example knee surgery. People don’t use private healthcare for emergencies or intensive care. For example the prime minister was in intensive care in April - in an NHS hospital.

Same in countries with public healthcare in the EU; when you have an emergency, you end up in public healthcare (which, in the countries I have lived in, is excellent), when you have a knee or hip operation, you benefit from private if you have it.

It would be surprising if in any EU country private clinics dealt with covid19 unless you're maybe super rich with personal doctors around you all the time.

Reading the full paper, the population surveyed was people registered for at least one year with General Practice doctors using SystmOne software. That covers 40% of the English population. It is probably safe to assume that almost everyone in England is registered with a GP. There is variance in the GP use of the specific SystmOne software - the paper mentions on page 13 that only 17% of London GP practices use it.

The quirk of the UK system is that private insurance companies have no legal or moral obligation to cover anything as you will always be able to fall back to the NHS. So getting cover than includes preexisting conditions or severe long term illness (e.g. MS) is very expensive and rarely negotiated by employers except in firms who can afford to do it.

Private healthcare providers in the UK don't seem to be providing hospital treatment for COVID-19 - this is left to the NHS, BUPA says:

"As a public health emergency, COVID-19 is being treated through the public health system."

https://www.bupa.co.uk/coronavirus/health-insurance

Not that private healthcare providers are actually providing resources to the NHS so its possible that you could end up in a private hospital even though you don't have private health insurance.

This is pretty common in places with dual systems, my wife just had surgery on her shoulder in a private clinic but paid for by the public system.

Currently private hospitals in England were requisitioned to cope with surge demand for NHS patients. They're going to reopen to private patients soonish.

https://www.bbc.co.uk/news/uk-england-london-52381675

What does deprivation mean here?

Early in the outbreak I remember seeing some research that indicated people of Asian descent (East Asian) are genetically predisposed to more severe cases of this coronavirus, something to do with higher expression of the ACE-2 receptor.

It means poor.

It's unclear to me (only skimmed the figures) if the various ethnic/racial hazard factors correct for poverty (deprivation) or not.

They took that into consideration:

> People from Asian and black groups are at markedly increased risk of in-hospital death from COVID-19, and contrary to some prior speculation this is only partially attributable to pre-existing clinical risk factors or deprivation;

I noted that. However, "partially attributable" doesn't suggest to me one way or the other whether or not they corrected for that impact in figure 3. Or maybe I'm misreading the sentence.

The UK BAME population is largely located in a couple of Large more densely populated cities. Whereas the country as a whole is around 87% white, London has areas with < 50% white people, for example Newham/Straford is 70% non white[1].

Surely the geographical relationship between dense cities and their inhabitants demographics is more than enough to explain it.

[1] https://www.newham.info/population/

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