Geographical inequalities in the evolution of the COVID-19 pandemic: An ecological study of inequalities in mortality in the first wave and the effects of the first national lockdown in England

Abstract

Objectives This is the first study to examine how geographical inequalities in COVID–19 mortality rates evolved in England, and whether the first national lockdown modified them. This analysis provides important lessons to inform public health planning to reduce inequalities in any future pandemics. Design Longitudinal ecological study Setting 307 Lower-tier local authorities in England Primary outcome measure Age-standardised COVID–19 mortality rates by local authority and decile of index of multiple deprivation. Results Local authorities that started recording COVID–19 deaths earlier tended to be more deprived, and more deprived authorities saw faster increases in their death rates. By 2020–04–06 (week 15, the time the March 23rd lockdown could have begun affecting deaths) the cumulative death rate in local authorities in the two most deprived deciles of IMD was 54% higher than the rate in the two least deprived deciles. By 2020–07–04 (week 27), this gap had narrowed to 29%. Thus, inequalities in mortality rates by decile of deprivation persisted throughout the first wave, but reduced somewhat during the lockdown. Conclusions This study found significant differences in the dynamics of COVID–19 mortality at the local authority level, resulting in inequalities in cumulative mortality rates during the first wave of the pandemic. The first lockdown in England was fairly strict – and the study found that it particularly benefited those living in the more deprived local authorities. Care should be taken to implement lockdowns early enough, in the right places – and at a sufficiently strict level – to maximally benefit all communities, and reduce inequalities.

The effects of the first national lockdown in England on geographical inequalities in the evolution of COVID-19 case rates: An ecological study

“…Our findings align with the fundamental causes theory proposed by Clouston et al (2021) on stages of disease transmission and the generation of health inequalities 2 . However, our recent analyses of geographical inequalities in mortality found that whilst death rates were higher across the first wave in more deprived areas, the lock down did reduce them 22 .…”

“…Our findings align with the fundamental causes theory proposed by Clouston et al (2021) on stages of disease transmission and the generation of health inequalities 2 . However, our recent analyses of geographical inequalities in mortality found that whilst death rates were higher across the first wave in more deprived areas, the lock down did reduce them22 .Reduced viral load across the country is an important aim that benefits all inhabitants, through a reduction in selection pressure on the virus, and reduced demand on healthcare. Lockdowns are an effective means of achieving this aim quickly, however their potential harms need to be carefully weighed, and their timings carefully considered -and to reflect both local and national need.…”

Explaining the deprivation gap in COVID-19 mortality rates: A decomposition analysis of geographical inequalities in England

“…the 20% most deprived LAs compared to the rest of the country). We chose to focus on the bottom 20% because in previous work ( Welsh et al, 2021a ), we found that the 20% most deprived local authorities had the highest COVID-19 age-standardised mortality rates during the first wave and that these bottom two deciles had significantly higher death rates than the other eight deciles. The relationship between IMD and COVID-19 mortality rates was also not linear in the first wave (e.g.…”

“…Weekly counts of COVID-19 deaths (based on any mention of Coronavirus in the death certificate) for the study sample of LAs (n = 311) were obtained from the UK Office for National Statistics (ONS) by date of registration ( Timson, 2021 ) for the period 1 st January 2020 to 4 th July 2020, the date at which many service and hospitality establishments were allowed to re-open to the public ( Department for Business, 2020 ; Prime Minister's Office, 2020 ). Age-standardised weekly COVID-19 death counts were approximated using monthly age-standardised rates available from the ONS ( Office for National Statistics, 2021b ; Welsh et al, 2021a ).…”

“…For example, in the USA, COVID-19 mortality rates are more than twice as high in low-income counties than in the wealthiest counties ( Chen and Krieger, 2021 ). Similarly, in England, the cumulative death rate in the most deprived 20% of local authorities was 54% higher than the rate in the 20% least deprived areas at the start of the pandemic, with inequalities even persisting during- and after-the first national lockdown ( Welsh et al, 2021a ). A similar picture has been reported for COVID-19 cases in England ( Morrissey et al, 2021 ; Welsh et al, 2021b ).…”