On 29 June 2020, the secretary of state for health, Matt Hancock, announced in Parliament that Leicester was to be put under local lockdown due to a covid-19 “outbreak” in the city. The majority of the population in Leicester is of non-white ethnicity, and it is the first city in England to go into a local lockdown. [1] Anxiety within the city has been high since the outbreak in part due to people from deprived and ethnic minority groups being more at risk of increased hospitalisation and mortality from covid-19. The reasons for this are complex and not completely elucidated. 

What is clear is that we must ensure inequalities in access are not perpetuated in the implementation of a national find, test, trace, isolate, and support (FTTIS) programme. Past evidence from screening programmes for other infectious diseases, cancer screening, and research show lower rates of participation for ethnic minority populations in the UK. [2,3,4] The spike in cases in Leicester is unlikely to be the only one with recent easing of lockdown. So what can be done to ensure that further local lockdowns can be avoided and better managed?

The Public Health England (PHE) Rapid Investigation Team Report shows that most positive cases were tested under the commercial Pillar 2 and there were delays in getting these data to PHE and to the local public health teams. [5] The report also shows that ethnicity data were only available for half the confirmed cases. It is vital that surveillance data on those tested are available locally in real time and specific at postcode level to support informed local decision making and outbreak control. Specifically the government should publish data by age, gender, and ethnicity on the numbers being tested and outcomes of testing through the many different routes including NHS 111, covid assessment centres, primary care referrals, mobile units, and for tests ordered online or through the government phone line. Ideally anyone with symptoms should report to primary care or NHS 111 to ensure, rapid referral for testing, accurate interpretation of test results and rapid notification of suspected cases. Tests ordered and administered by health professionals reduce the risks of poor uptake and false negative tests which have been demonstrated previously due to poor understanding in ethnic minority groups. [6] 

A test is a complex intervention, and so too are requests for details of contacts and advice to self isolate. The latest release of Test and Trace data show only around half of all cases so far have provided details of contacts and most of the contacts reached and identified have been by the local public health outbreak management teams, not the centralised service of private call handlers. No statistics have been published so far on the proportion of cases and contacts that have been identified and reached, stratified by age, gender, and ethnicity. There are no published data on the numbers of people in need of and in receipt of translation services. There are no data on the proportion of cases and contacts who have agreed to self isolate or quarantine, or of their outcomes. 

Participation in testing and in contact tracing requires a high degree of support and trust. Research from screening programmes highlight multiple barriers to participation including beliefs and attitudes, language, stigma, fear, lack of knowledge and awareness, access and potential gender differences. [2, 3] For example, limiting any FTTIS material to only English could led to the exclusion of 30 – 40% of south Asians living in the UK. [7]

Ethnic minority groups are a heterogenous group and implementation of a FTTIS programme needs to be relevant to each individual community. Multifaceted interventions can improve the uptake of screening in ethnic minority populations. [8] These include use of lay health workers and navigators, working with community organisations including faith groups to raise awareness of the benefits of screening for individuals as well as for the community. [9-11] Unless the FTTIS programme has been planned with these issues in mind, it may have limited efficacy within these populations

Any digital app solutions for testing and contact tracing must meet the needs for those already disproportionately affected groups to prevent widening inequalities in these populations. All digital solutions should be pilot tested with careful monitoring of uptake, engagement, and effectiveness. 

A FTTIS programme must have a locally embedded infrastructure with involvement of public health and infectious disease specialists, primary care, schools, community and religious groups and a network of locally based volunteer sector organisations. These groups have the local knowledge of their populations, can speak different languages, and will be culturally aware. They will also require education and training in understanding control of local outbreaks. Communication through local community channels is vital. Although local religious and community centres have closed, many community groups are continuing to be active virtually including local radio stations and social media for religious activities. These are important outlets for communication and information. Local pharmacists with relevant language skills can also play major roles in preventative strategies in local communities. Crucially provision will need to be made for those cases or contacts who are advised to self isolate or quarantine.

Individuals who have tested positive will need to be supported with provision for alternative accommodation in particular multigenerational families, key workers and those who are homeless. This will also need to include provision of food and essentials. If individuals are to comply with isolation, then employers need to ensure that those isolating are paid and do not endure financial hardship.

Ethnic minority groups have been disproportionately and severely affected by covid-19 and policy makers need to urgently ensure their needs are understood and addressed. Lockdown restrictions are being eased further in the UK. Unless localised FTTIS are planned and rehearsed in the event of a  future outbreak, we are likely to see further widening of disparities. 

Kamlesh Khunti, Professor, Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK

Allyson M Pollock, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK

Manish Pareek, Department of Respiratory Sciences, University of Leicester, UK

Competing interests: KK is supported by the National Institute for Health Research (NIHR) Applied Research Collaboration East Midlands (ARC EM). KK and MP are supported by the NIHR Leicester Biomedical Research Centre (BRC). The views expressed are those of the author(s) and not necessarily those of the NIHR, NHS or the Department of Health and Social Care. KK is Director for the University of Leicester Centre for Black Minority Ethnic Health and the National NIHR ARC lead for Ethnicity and Diversity. KK and AMP are members of the Independent SAGE. 

 

References:

2. BBC News. Coronavirus: Leicester lockdown tightened as coronavirus cases rise. [Available from: https://www.bbc.co.uk/news/uk-england-leicestershire-53229371 Accessed on June 29th 2020.
3. Crawford J, Ahmad F, Beaton D, Bierman AS. Cancer screening behaviours among South Asian immigrants in the UK, US and Canada: a scoping study. Health Soc Care Community. 2016;24(2):123-53
4. Olufikayo B, Nasreen A, Papadopoulos C, Randhawa G. Exploring Factors Contributing to Low Uptake of the NHS Breast Cancer Screening Programme among Black African Women in England2017; 4(14):[212-19 pp.]. Available from: https://uobrep.openrepository.com/handle/10547/622571. Accessed on June 29.
5. Treweek S, Forouhi NG, Narayan KMV, Khunti K. COVID-19 and ethnicity: who will research results apply to? Lancet. 2020;395(10242):1955-7.
6. Public Health England. 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
7. Roderick P, Macfarlane A, Pollock AM. Getting back on track: control of covid-19 outbreaks in the community. BMJ 2020;369:m2484
8. GOV.UK. English language skills 2018 [Available from: https://www.ethnicity-facts-figures.service.gov.uk/uk-population-by-ethnicity/demographics/english-language-skills/latest#by-ethnicity. Accessed on 29 June 2020.
9. Dharni N, Armstrong D, Chung-Faye G, Wright AJ. Factors influencing participation in colorectal cancer screening-a qualitative study in an ethnic and socio-economically diverse inner city population. Health Expect. 2017;20(4):608-17.
10. Kelly C, Pericleous M, Hendy J, de Lusignan S, Ahmed A, Vandrevala T, et al. Interventions to improve the uptake of screening across a range of conditions in Ethnic Minority Groups: a systematic review. Int J Clin Pract. 2018:e13202.
11. Seedat F, Hargreaves S, Friedland JS. Engaging new migrants in infectious disease screening: a qualitative semi-structured interview study of UK migrant community health-care leads. PloS one. 2014;9(10):e108261.
12. Willis A, Roshan M, Patel N, Gray LJ, Yates T, Davies M, et al. A community faith centre based screening and educational intervention to reduce the risk of type 2 diabetes: A feasibility study. Diabetes research and clinical practice. 2016;120:73-80.