The residents of Leicester are devastated that their city has become the first city in England to be put under a strict local lockdown. It was imposed due to the first major spike in cases of covid-19 since the initial outbreak in England. It is a major blow for the proud multicultural people of Leicester to see the city and its inhabitants being viewed in a negative light. 

The city’s early experience of lockdown was very similar to other areas of England. The East Midlands region as a whole had the second lowest regional rate up until June. However, last week, 10% of all cases of coronavirus in England were identified in Leicester. [1]  The reason for this sudden rise in the number of cases is unclear, although high levels of social deprivation and ethnic diversity may have increased the risk. The first signs of this outbreak were reportedly detected as early as the end of May, but residents were not made aware until a government daily briefing shortly before lockdown was imposed. 

So why have restrictions been less effective in Leicester when they have proved successful at reducing covid-19 cases elsewhere? Leicester is one of the most ethnically diverse cities in England and evidence indicates that individuals from ethnic minority groups are at increased risk of adverse clinical outcomes. [2] 

Public health messaging on social distancing is difficult to implement in small and multigenerational households, which are common in these communities. The identification of stakeholders and community influencers is a key part of the local authority’s plan to maximise awareness and change behaviours. [3] The council has already made efforts to ensure that information, in a variety of formats, is available in the most commonly spoken languages in the city. 

An additional risk factor is that a high proportion of individuals from ethnic minority communities are employed as essential workers in sectors such as health and social care, transport, and manufacturing. Their risk of exposure to coronavirus is ongoing and unlikely to be changed by a local lockdown. 

Another major contributing factor to Leicester’s outbreak is social deprivation, with one in six residents living in areas of high health deprivation with increased rates of illness and disability and a lower life expectancy. [4]  These areas were disproportionately affected by the initial covid-19 outbreak and increased efforts to engage residents with public health interventions is critical in managing this new spike. [5] Bradford and Rochdale have recently been highlighted as having a high incidence of new cases in the community, both of which have high levelss of social deprivation and large ethnic minority communities. [1,6]

Local lockdowns pose new challenges. The lack of a legal framework and imperceptible geographical borders make it difficult to envisage what restrictions on movement can realistically be enforced. As the government works on the necessary legislature, the council and local police force have both criticised the lack of specific guidance on local lockdown restrictions. [7]  Small businesses and their employees will continue to be significantly impacted and so the provision of targeted business support is clearly required during a local lockdown. 

A vital tool for controlling an outbreak and preventing further spikes is testing in the community. Nationally, testing capacity has increased since the first lockdown and has now been further intensified in Leicester, with an additional five mobile testing units deployed in the affected areas. However, communication of these pillar 2 tests has been heavily criticised due to significant delays in sharing comprehensive demographic data with the local authority. [8] Supplied with pillar 2 testing data, local health authorities will be best placed to implement targeted and timely interventions and assist in the national contact tracing programme. 

Of grave concern is the emergence of a common thread in areas experiencing a second spike in new cases of covid-19—social deprivation and a large ethnic minority population. We must learn lessons from Leicester’s experience to prevent further outbreaks in these communities. Increased testing and contact tracing capacity must be used and rapidly deployed to avoid the use of damaging local lockdowns. 

Joshua Nazareth, Department of Respiratory Sciences, University of Leicester, UK.

Kamlesh Khunti, professor of Primary Care Diabetes and 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.

Competing interests: JN: none to declare. KK is National lead for Ethnicity and Diversity for NIHR Applied Research Collaboration, Director of the University of Leicester Centre for BME Health and member of Independent SAGE. MP reports grants and personal fees from Gilead Sciences and personal fees from QIAGEN, outside the submitted work.

References: 

1. Preliminary investigation into COVID-19 exceedances in Leicester (June 2020) https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/897128/COVID-19_activity_Leicester_Final-report_010720_v3.pdf
2. Pan D, Sze S, Minhas JS, et al. The impact of ethnicity on clinical outcomes in COVID-19: A systematic review. EClinicalMedicine. 2020;23:100404. doi:10.1016/j.eclinm.2020.100404
3. Leicester City Council Covid-19 Local Outbreak Control Plan https://www.leicester.gov.uk/media/186741/leicester-city-council-covid-outbreak-management-plan-v6-june-2020-004.pdf. 
4. Indices of deprivation in Leicester September 2016 https://www.leicester.gov.uk/media/181928/indices-of-deprivation-in-leicester-september-2016.pdf
5. Beyond the data: Understanding the impact of COVID-19 on BAME groups https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/892376/COVID_stakeholder_engagement_synthesis_beyond_the_data.pdf 
6. UK 2011 Census data via: Towns and cities analysis, England and Wales, March 2016 https://www.ons.gov.uk/peoplepopulationandcommunity/housing/articles/townsandcitiesanalysisenglandandwalesmarch2016/2016-03-18 and Ethnic group, local authorities in England and Wales https://www.ons.gov.uk/file?uri=/peoplepopulationandcommunity/populationandmigration/populationestimates/datasets/2011censuskeystatisticsforlocalauthoritiesinenglandandwales/r21ewrttableks201ewladv1_tcm77-290595.xls
7. Leicester lockdown: Police given ‘minimal guidance’ on new restrictions https://www.bbc.co.uk/news/uk-england-leicestershire-53236467
8. Lack of local Covid-19 testing data hinders UK’s outbreak response https://www.ft.com/content/301c847c-a317-4950-a75b-8e66933d423a