We need to move on from describing the problem to developing recommendations and a rapidly implemented action plan

Early reports from the Intensive Care National Audit and Research Centre (ICNARC) coupled with clinical observations from frontline clinicians from Europe and North America highlighted that individuals from ethnic minority groups with covid-19 appeared to be at increased risk of severe disease and mortality. [1-3] The lack of clarity on this matter was compounded by the fact that routine reporting of ethnicity for those individuals who had died was not mandated. As a result public health authorities and the UK government were on the back foot from the outset. [4] 

In response to the emerging evidence of disparities in outcomes by ethnic group, the Department of Health tasked Public Health England (PHE) with reviewing the data on disparities in clinical outcomes across a wide range of groups, including individuals from different ethnic groups. It remains unclear what PHE were going to achieve from this review as their terms of reference at the outset stated both “the review will not ascertain root causes of findings that are likely to be driven by complex interactions” and “suggest recommendations for further action that should be taken to reduce disparities in risk and outcomes from covid-19 on the population.” [5] 

Over the month that PHE compiled their report, the evidence-base rapidly evolved and other multiple groups/organisations, including the Office for National Statistics, published their data which confirmed that individuals of black and asian ethnicity were at increased risk of death from covid-19. [4,6] As well as male sex and older age, all the evidence to date has consistently shown that severity of covid-19 and mortality are associated with obesity, long term conditions including diabetes, cardiovascular disease, hypertension, and coming from a socioeconomically deprived population. All of these risk factors are more common in ethnic minority populations. Moreover, others highlighted that healthcare workers from ethnic minority communities made up the majority of those dying from covid-19. [7] There was therefore an eagerness to understand what PHE’s report would add to this evidence base. 

PHE’s report was eventually published last week. [8] By their own admission it was a descriptive report which largely confirmed what we already knew about the risk of infection, admission to intensive care and death in different ethnic groups, but, interestingly, does highlight that country of birth is an important risk factor. However, their analyses are significantly hampered by being unable to control for potential confounders including occupation and comorbidities. Most critically, however, the report failed to make any recommendations on how to reduce the risk in ethnic minority communities, even though this was in its initial terms of reference. This was a missed opportunity to address significant inequalities in ethnic minority communities, not only in the context of covid-19, but more widely. 

In the absence of any recommendations from PHE, what can be done? It is important to understand that this is an urgent public health emergency. Therefore, it is simply not correct that we sit and do nothing. It is imperative that the UK government and PHE move on from description to developing recommendations and a rapidly implemented action plan. The least that could be done in the short term is to make recommendations with a specific focus on how to reduce the risk of infection, ITU admission, and death in ethnic minority communities. These include refined/targeted public health messages which are culturally-tailored for ethnic minority groups, and in their own spoken/written languages. We need methods of reducing transmission risk in larger, intergenerational, households through hygiene methods or provision of alternative accommodation to reduce household size and facilitate shielding (where appropriate). Finally, we must provide universal occupational risk assessments for ethnic minority staff within healthcare and those in public facing roles, with appropriate strategies to reduce the risk in those at the highest risk. [9] Similarly a culturally appropriate strategy will need to be implemented for the forthcoming test, trace, and isolation programme. 

What can be done in the medium to longer term? The disparities that the covid-19 pandemic has exposed exist not only in ethnic minority communities, but reflect in populations from more disadvantaged areas, reflecting the wider determinants of health. The first cases of covid-19 deaths were reported in February which coincided with the publication of the “Marmot Review: 10 years on”. [10] Covid-19 has highlighted that these determinants of health in disadvantaged populations will be heightened further during times of pandemics. In the medium term, recommendations from the Marmot review for action on social determinants of heath across the whole of society are more important than ever.

PHE’s recent report was an opportunity to take the lead on the disproportionate impact that covid-19 has had on ethnic minority communities and in those from deprived communities. Unfortunately, this has not been operationalised and, therefore, there is an urgent need for the government to come together with key stakeholders to develop clear, practical, evidence-based recommendations which will reduce morbidity and mortality in ethnic minority individuals. Failure to take action now will further widen the disparities in those from the most deprived populations. 

Kamlesh Khunti, professor of Primary Care Diabetes & Vascular Medicine, Diabetes Research Centre, Leicester General Hospital, University of Leicester.

Manish Pareek, associate Clinical Professor in Infectious Diseases, Department of Infection and Tropical Medicine, Leicester Royal Infirmary.

Funding sources: MP and KK acknowledge the NIHR Applied Research Collaborations – East Midlands, the NIHR Leicester Biomedical Research Centre and the Centre for Black Minority Ethnic Health. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Declaration of interests: MP received grants and personal fees from Gilead Sciences outside of the submitted work.

References:

1. Intensive Care National Audit and Research Centre (ICNARC). Report on 2249 patients critically ill with COVID-19. 2020 [Available from: https://www.icnarc.org/ Our-Audit/Latest-News/2020/04/04/Report-On-2249- Patients-Critically-Ill-With-Covid-19 accessed June 6 2020.
2. Pareek M, Bangash MN, Pareek N, et al. Ethnicity and COVID-19: an urgent public health research priority. Lancet (London, England) 2020;395(10234):1421-22. doi: 10.1016/s0140-6736(20)30922-3 [published Online First: 2020/04/25]
3. Khunti K, Singh AK, Pareek M, et al. Is ethnicity linked to incidence or outcomes of covid-19? BMJ 2020;369:m1548. doi: 10.1136/bmj.m1548
4. Pan D, Sze S, Minhas JS, et al. The impact of ethnicity on clinical outcomes in COVID-19: A systematic review. EClinicalMedicine doi: 10.1016/j.eclinm.2020.100404
5. Public Health England. Terms of reference: Review into disparities in the risk and outcomes of COVID-19. London: Public Health England 2020.
6. Statistics OfN. Coronavirus (COVID-19) related deaths by ethnic group, England and Wales: 2 March 2020 to 10 April 2020: ONS; 2020 [Available from: https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronavirusrelateddeathsbyethnicgroupenglandandwales/2march2020to10april2020 accessed June 6 2020.
7. Cook T, Kursumovic E, Lennane S. Exclusive: deaths of NHS staff from covid-19 analysed: Health Services Journal; 2020 [Available from: https://www.hsj.co.uk/exclusive-deaths-of-nhs-staff-from-covid-19-analysed/7027471.article accessed June 5 2020.
8. Public Health England. Disparities in the risk and outcomes of COVID-19. London: Public Health England 2020.
9. Khunti K, de Bono A, Browne I, et al. Risk Reduction Framework for NHS Staff at risk of COVID-19 infection. London: Faculty of Occupational Medicine 2020.
10. Marmot M, Allen J, Boyce T, et al. Health equity in England: The Marmot Review 10 years on. London: Institute of Health Equity 2020.