Background This study aims to estimate ethnic inequalities in risk for SARS-CoV-2 infections, COVID-19 hospitalisations and deaths over time in Scotland.

Methods We conducted a population-based cohort study where the 2011 Scottish Census was linked to health records. We included all individuals 16 years living in Scotland on March 1 ,2020, with follow-up to April 17, 2022. Self-reported ethnic group was taken from the Census and Cox proportion hazard models estimated hazard ratios (HRs) for COVID-19 infections, hospitalisations and deaths, adjusted for age, sex, and health board. We also conducted separate analyses for each of the four waves of COVID-19 to assess changes in risk over time.

Results Of the 4,358,339 individuals analysed, 1,093,234 SARS-CoV-2 infections, 37,437 hospitalisations, and 14,158 deaths occurred. The risk of COVID-19 hospitalisation or death among ethnic minority groups was often higher for White Gypsy/Traveller (HR 2.21, 95% CI (1.61- 3.06)) and Pakistani 2.09 (1.90–2.29) groups compared with White Scottish. The risk of COVID-19 hospitalisation or death following confirmed infection was particularly higher for White Gypsy/Traveller 2.55(1.81–3.58), Pakistani 1.75(1.59–1.73), and African 1.61(1.28–2.03) relative to White Scottish. However, COVID-19 related deaths following hospitalisation did not differ. The risk of COVID-19 outcomes for ethnic minority groups was higher in the first three waves compared to fourth wave.

Conclusion Most ethnic minority groups were at increased risk of adverse COVID-19 outcomes in Scotland, especially White Gypsy/Traveller and Pakistani groups. Ethnic inequalities persisted following community infection but not following hospitalisation, suggesting differences in hospital treatment are not substantially contributing to ethnic inequalities.