COVID19: Why Not Lock Up The Old Folks?
by Raywat Deonandan, PhD
Epidemiologist & Associate Professor
University of Ottawa
(I add my credentials to these COVID-19 blog posts in case they get shared. I want readers to know that my opinion is supposedly an educated and informed one)
We are a few weeks into this pandemic, and I’ve been getting many interesting questions from journalists and the public. A few questions pop up more often than others. So today I will take a moment to answer one of them.
Remember, this is still a personal blog. So here’s a list of my media contributions since the last blog post, just so I have a record of them somewhere:
- April 15, 2020 — interviewed on CJOB radio in Winnipeg
- April 15, 2020 — interviewed by CBC News for article, “When is someone considered ‘recovered’ from COVID-19?”
- April 13, 2020 — interviewed by CBC Quebec for article, “Devrait-on rouvrir les écoles? Les experts sont partagés“
- April 11, 2020 — interviewed on CTV News
- April 10, 2020 — interviewed for this CBC News article, “Number of COVID cases climbs to 285 with roughly half in people under 44“
Also, my podcasting compatriot Dr Graham Sanders and I have recorded a special video version of our audio show “Science Monkey” all about COVID-19. You can watch it here.
Lock Up The Old Folks
Probably the most common question I get from well-meaning members of the general public is: Why don’t we just quarantine the old people and let the rest of us get on with our lives? We’re doing this presumably to protect them, right? So why do we all have to be “quarantined”?
There are several parts to my answer. Stay with me here.
Who Are The Vulnerable?
The central premise of this question is that it’s the old folks who are going to die. We think this because initial reports out of China characterized this as an old people’s disease. Recent data from New York City confirm this sentiment:
But it’s not completely an age thing. A pre-peer reviewed systematic review of COVID-19 comorbidities found that COPD, cardiovascular disease, hypertension, and dyspnoea were all strongly predictive of a bad experience with COVID-19 requiring hospitalization.
USA Today recapitulated its findings by compiling CDC data to show the common underlying conditions in the US population:
The same article summarized what we know of underlying conditions among Americans who died of COVID-19: hypertension, diabetes, cardiovascular disease, and others.
And it’s not just these conditions. As per the CDC, “people with moderate to severe asthma may be at higher risk of getting very sick from COVID-19.”
Here’s another view of the American data. The CDC published this table of underlying conditions of SARS-CoV-2 hospitalized infectees:
See that second one? Obesity. Among the hospitalized young-ish Americans (18-49), 59% of them are obese.
The NY Times reports that, “new studies point to [obesity] in and of itself as the most significant risk factor, after only older age, for being hospitalized with Covid-19.” The article continues to note that, “young adults with obesity appear to be at particular risk.”
And that’s the thing, right? It’s a mistake to think of COVID-19 as a threat to just the elderly. A host of underlying conditions heighten our risk of serious disease and even death. Obesity, or simple overweight, is the most troubling to me. The Childhood Obesity Foundation states that in Canada, “the combined prevalence of overweight and obesity among those aged two to 17 years increased from 23 per cent to 34%.”
That means that maybe a third of children are at risk for serious complications to COVID-19. And while childhood obesity is on the rise in China, it’s not at North American levels yet. This makes me nervous for our children.
Let’s look at Canadian hospitalization rates:
Another way to look these data is through an age pyramid:
What these data show is that a fair proportion of serious COVID-19 cases are in fact among the younger age groups. Now, this is not the same as reporting the actual risk of being hospitalized with COVID-19 if you’re young. For that, look at this graph from Statista:
It suggests that the risk of hospitalization among the “young” hovers around 20% for those 20-65. That’s not a trivial number. Frankly, I think it’s too high. It’s probably <5% when all is said and done.
And let’s not forget about smoking. The WHO reports, “early research indicates that, compared to non-smokers, having a history of smoking may substantially increase the chance of adverse health outcomes for COVID-19 patients, including being admitted to intensive care, requiring mechanical ventilation and suffering severe health consequences.”
Who smokes? Well, it ain’t just old people.
Well? Who Are The Vulnerable?
Here’s the thing: we really don’t know who the vulnerable are. To quote Vox, “individual differences in immune response could lead one person to severe disease and another one to be fine.”
In other words, some people might just be genetically predisposed to doing poorly. At present, we can’t reliably predict who those people will be.
Yeah But… Why Can’t We Lock Up The Old People?
Look, it’s pretty clear that we don’t know who the vulnerable are. It’s not just old people. If we quarantined just the vulnerable –the smokers, the asthmatics, the diabetics, the obese and overweight, and the elderly– we’re going to be letting a small portion of society move about freely.
And how do much you want to bet those people end up infecting the “quarantined” people anyway, given that some contact is unavoidable?
But let’s say that we did quarantine the elderly (65 years and above). That leaves about 83% of the the Canadian population walking around freely, or 30.7 million people. The idea is for these people to freely become infected and thereby achieve herd immunity.
As explained in an earlier post, herd immunity for this disease is likely achieved at 60% infection, or about 18 million people. (Really, though, we should be looking at herd immunity for the full population, or 22 million. But let’s be generous.)
The current hospitalization rate for cases in Canada is 6.8%. But that’s being driven by the elderly, for sure. As noted above, though, a fair number of non-elderly are also hospitalized. From the chart above, 38% of Canadian COVID hospitalizations are under 60.
So let’s be generous with our quick-and-dirty calculations and say that the hospitalization <38% of that 6.8% or about 2%. So 2% of COVID-19 cases of young people will need to be hospitalized.
Two percent of 18 million people is 360,000 people. That’s the number of young Canadians hospitalized if we let COVID-19 run rampant in a society with the old folks locked up. And that’s making very generous assumptions.
Canada has 57000 hospital beds. About 3/4 of those beds are occupied at any given time. So we’d be reaching and exceeding our true hospitalization capacity very quickly indeed.
In addition, the current case-fatality rate of COVID-19 in Canada is >3%. It is my opinion that when applied to the whole population, that number will come down substantially. So let’s be really optimistic and say the true CFR is 0.3%. When applied to our population of infected young Canadians, that means 54,000 deaths.
Fifty-four thousand dead young people. A health care system that is still stressed and likely overwhelmed. And that’s not even considering the fact that these numbers are likely vast underestimates, given the realities explored above, of other comorbidities like obesity and asthma.
Those Are A Lot of Deaths, But But But… The Economy!
I get it. I’m worried about the economy too. At some point the negative public health impacts of the diminished economy may exceed the public health impacts of the disease itself. We have to be on guard for that moment.
But it’s not here yet.
Infection with and recovery from COVID-19 likely brings with it immunity, hence our expectation that herd immunity will result. But, honestly, that’s not a guaranteed thing. Official science has still not brought back a verdict yet.
As well, infection and recovery also come with some long term, and possibly permanent, disability. One of the more horrifying outcomes for me is lung fibrosis. Imagine having permanently impaired lung function after weeks of coughing up your innards.
Probably the best argument for not rushing out to achieve natural herd immunity, but rather to wait for artificial herd immunity granted by a vaccine, is that we learn more every day about how to treat this thing. Assuming a working health care system, you are much less likely to die of it today than you were yesterday. Everything from new therapies to how to fiddle with the ventilator settings are nuggets of wisdom being gleaned every hour.
So imagine if one of your loved ones was one of those 54,000 young people sacrificed in short order to save the economy. And imagine again that they would have lived if only they had acquired the disease a couple of months later.
Locking up the old folks and letting the disease run wild through the young in order to hasten herd immunity and sustain the economy is a bad idea. Don’t do it.