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
Authors: Welsh Claire E. , Albani Viviana , Matthews Fiona E. , Bambra Clare 
Published: October 2021

AbstractObjectivesThis 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.DesignLongitudinal ecological studySetting307 Lower-tier local authorities in EnglandPrimary outcome measureAge-standardised COVID-19 mortality rates by local authority and decile of index of multiple deprivation.ResultsLocal 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.ConclusionsThis 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 studyThis 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 BoxSection 1: What is already known on this subjectThere are cross-sectional estimates of geographical inequalities in the severity of the COVID-19 pandemic in England in terms of cases, hospitalisations and deaths. But these studies have not examined the evolution of the epidemic nor the impact of the national lockdown on inequalities in COVID-19 related mortality.Section 2: What this study addsThis study provides the first analysis of inequalities in the evolution of the pandemic in different English local authorities and the impact of the first national lock down on them. We estimate geographical inequalities by local authority in the evolution of age-standardised COVID-19 mortality during the first wave of the pandemic in England (January to July 2020) and the impact on these inequalities in the cumulative death rates of the first national lockdown. We found that more deprived local authorities started to record COVID-19 deaths earlier, and that their death rates increased faster. Cumulative COVID-19 mortality inequalities during the first wave of the pandemic in England were moderately reduced by first national lockdown.