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

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 23 ^rd 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.

Strengths and limitations of this study

• This study interrogates the evolution of inequalities in COVID-19 in the first wave of the pandemic in England and the impact of the national lock down.

• National level official (ONS) data used, covering nearly all local authorities in England and including all deaths that made any mention of COVID-19 on death certificates, requiring sensitive data acquisition.

• Age-standardised deaths rates at lower geographies are not available at the time of writing but could lend extra nuance to these findings.

• Ecological study not using individual level data, so unable to examine the individual level risks for covid-19 mortality.

Summary Box