release the young, protect the elderly: further consideration of an “open” covid policy

As loyal readers know, my position on COVID policy is simple: protect the elderly, release the young. Why? COVID is very low risk for young people, but extremely damaging for people who are older. This position is very much an “open” position. Here, I’ll discuss some recent evolutions in this argument.

First, Linkdn’s new website ran an article by Martin Kulldorff, who teaches at Harvard’s Brigham and Women’s hospital. In brief, he argues for a position similar to mine. Instead of society wide lock downs, we should be age focused. We should come up with policies that minimize costs on young people while reducing risk for older people. A few quotes:

With age 70-79 as baseline, relative mortality risks are shown in Table 1. For COVID-19 exposed individuals, people in their 70s have roughly twice the mortality of those in their 60s, 10 times the mortality of those in their 50s, 40 times that of those in their 40s, 100 times that of those in their 30s, 300 times that of those in their 20s, and a mortality that is more than 3000 times higher than for children. Under Scenario B, with higher exposure among the young, the age differences are even larger.

In other words, the risk of mortality for the elderly is 3000 times more than children. He admits that perfect information is not available, but what we do have suggests that burden of disease is incredibly lopsided.

This is not controversial. This age-COVID mortality association was established in the Spring and is the consensus view. Kulldorff is simply emphasizing what is widely known and accepted. What is unusual is that Kulldorff makes a rather simple argument: if young people are relatively unaffected, we can open much of society, so long as we screen by age. Key quote:

To date, most government mandated mitigation measures have either been age neutral, such as restaurant closures, or targeted at young and middle-aged people, such as school and office closures. A more appropriate age targeted approach is needed. Just as some pubs ban customers under the age of 21, government officials could set temporary upper age limits of say 50, 60, or 65 for visiting or working at restaurants, stores, offices, airports, and other public places. So, for example, while all 60-plus-year-old supermarket cashiers, gas station attendants, police officers, postal workers, garbage collectors and bus drivers should stay home, their younger colleagues should keep working, taking extra shifts as needed.

This is a direct implication of the epidemiology of the illness. If X is not affected and Y is affected, focus on Y and leave X alone. However, much of the discourse in the United States is about policies that affect everyone (like lockdowns) or policies that heavily burden the young (e.g., college and school closures).

In Jacobin magazine, Martin Kulldorff and his colleague Kathrine Yih argued this position further. A few more key quotes. This is Yih discussing the need to evolve policy beyond a simple “minimize cases” approach:

I don’t think it’s wise or warranted to keep society locked down until vaccines become available. There are nine vaccines in large-scale efficacy trials as of mid-September 2020, and my guess is that at least one will be approved for use in the United States by some time in 2021. But this is not certain to happen. Furthermore, neither the effectiveness nor the duration of immunity from any of these vaccines is known as yet.

There are additional uncertainties about how many vaccines can be manufactured, distributed, kept at the requisite temperatures, and administered in a short amount of time after authorization or licensure, and whether a sizeable portion of the population will refuse vaccination. So we can hope but we certainly can’t count on a vaccine saving us either as individuals or as a population in the short term.

Regarding policy, early in the US epidemic, based in part on the experiences of Italy and Spain, the urgency of “flattening the [epidemiologic] curve” was emphasized. It was indeed crucial to take steps to ensure that hospitals and health care resources not be overwhelmed, as they very nearly were in parts of New York City, for instance.

But I have been struck by how this emphasis on keeping the numbers down at all costs has not evolved with time. There is a kind of simplistic goal of keeping people from getting infected, period. Now this may seem like a worthy goal, but with a highly contagious respiratory virus to which most of the world’s population is probably still not immune, people are going to get infected. The virus will spread, quickly or less so, until herd immunity is reached.

In sum, policy can’t be stuck in March 2020, when the only thing we knew was that there was high mortality in a few spots. Now that we know more, we can change the policy. What should that be? Open institutions that have few older people in them. This is Martin Kulldorff:

Children and young adults have minimal risk, and there is no scientific or public health rationale to close day care centers, schools, or colleges. In-person education is critically important for both the intellectual and social development for all kids, but school closures are especially harmful for working-class children whose parents cannot afford tutors, pod schools, or private schools.

You might think this is isolated. But others are coming around to the “release the young, protect the elderly” policy. This is from a recent article in Science Magazine by Matthew Snape and Russell Viner. Key quote:

Abstract: Children have a low risk of COVID-19 and are disproportionately harmed by precautions.

How harmful is COVID for kids? Worst case is that it is similar to adults, but probably few kids get sick:

Evidence from contact-tracing studies suggest that children and teenagers are less susceptible to SARS-CoV-2 infection than adults; however, community swabbing and seroprevalence studies conducted outside of outbreak settings suggest that infection rates are similar to those in older age groups (13). Only half of children and teenagers with antibodies against SARS-CoV-2 have experienced symptoms, and there is growing evidence that there is a broad range of presentations, emphasizing the limitations of community-based prevalence studies based on testing only children with respiratory symptoms. Hospitalization for severe acute COVID-19 in children is rare, but among these pediatric inpatients, respiratory symptoms are more apparent than in infected children in the community (4). Case fatality in hospitalized children is, fortunately, relatively low at 1% (compared with 27% across all ages) (4).

Do kids spread a lot COVID at home? Not very much:

 Looked at from another perspective, when household outbreaks of infection have occurred, it appears that children were responsible for only a small minority of household introductions of the virus. Also, recent surveys found that reopening of schools in a number of European countries in April and May had no clear impact on community transmission, with cases continuing to fall in most countries after reopening (11).

Do school closures have real harmful effects on children? Probably:

School closures and attendant loss of other protective systems for children (such as limited social care and health visiting) highlight the indirect, but very real, harms being disproportionately borne by children and teenagers as a result of measures to mitigate the COVID-19 pandemic. In the UK, it is estimated that the impact on education thus far may lead to a quarter of the national workforce having lower skills and attainment for a generation after the mid-2020s, leading to the loss of billions of dollars in national wealth (11). Additionally, there are a variety of other harms to children’s health, including the risk of reemergence of vaccine-preventable diseases such as measles because of disruptions to immunization programs.

My serious hope is that these voices become more common. We need to move from “COVID is an existential threat to humanity that needs to be shut down at all costs” to “COVID is a disease with a specific population profile that mitigation policies need to reflect.” In other words, release the young, protect the elderly.

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Written by fabiorojas

September 24, 2020 at 4:45 pm

Posted in uncategorized

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  1. Your position assumes that younger people haven’t got families and that older people are locked away from social interaction. If society is divided into young and old in impenetrable bubbles, what happens to the elderly or the young-but-at-risk? do we create society-wide equivalents of nursing homes without anyone of younger ages providing care or intimacy? At what age do older people get segregated?

    Liked by 1 person


    September 28, 2020 at 3:19 pm

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