Preventing COVID deaths in the elderly: the need to think beyond vaccination.

Reports are coming in from several countries in Europe about an alarming rise in COVID-19 infections and deaths in the age groups over 65, with Omicron variant. This is occurring despite vaccination and booster rates close to 100% in these age groups.

Unfortunately, there is a popular narrative that the “pandemic is over” and “precautions can be discarded”. This is not only wrong, but also dangerous – particularly for the elderly segment of our population.

COVID-19 does not affect all age groups with the same severity. Death rates are exponentially higher in the oldest age groups.

For instance, a 20-year-old will almost certainly survive an outbreak, but that might not be the case for an 80-year old who got infected at the same social gathering.

This article is written specifically about protecting the elderly. After the detailed discussion, 10 practical points are given at the end.

Let us examine three sets of data: from US, Kerala and Tamil Nadu, India.

Summary slides are included.

1) In the US, COVID-19 death rate in people of age 75-84 years is 140 times x that of young adults 18-29 years, and 2600 times x that of children 5-11 years.

For those who are over the age of 85, the risk is 330 times that of young adults 18-29 years, and 6300 times that of children 5-11 years.

(These are based on the latest total reported COVID deaths by age group from the US. The rates have been adjusted for population: note that the age pyramid is narrow at the top, which means the denominator is smaller for the oldest age groups)

2) Kerala COVID-19 death data, published above, also shows a steep gradient between the extremes of age groups. Death rate in people over 60 was approximately 320 times higher than in children, and 44 times* that of adults 18-40.

(*The multiple will be higher when adults 18-29 are compared as in US data above, but further age breakdown is not available for Kerala data)

3) Excess mortality study from Chennai, published in Lancet Infectious Diseases in December 2021 shows a similar trend (see slide). Excess mortality is an indirect indicator of COVID deaths in a population.

(In younger people, the total death rate actually fell because of fewer accidents and infections, and because COVID deaths are extremely rare in this age group)

Have our public health efforts done justice to this risk?

Unfortunately, our recent pandemic control measures have not fully addressed this enormous risk.

The following example shows how we often fail to direct our efforts in proportion to risks involved.

Example: Many people are obsessed about reducing blood cholesterol levels. They visit labs to periodically ‘check their cholesterol levels’ and often seek “cholesterol-lowering” medications. People carefully watch what they eat, avoiding “oily foods”, and talk about it as though that was the most important lifestyle advice.

However, for all the effort put in, few people realise that high cholesterol level increases risk of death from heart attack only 1.5 times.

In comparison, the COVID death risk faced by an older person is of the order of 100 to 330 times that of young adults - a lot more than 1.5 times, yet does not receive the importance it deserves.
COVID-19 is a disease that is severely biased towards older people. Vaccination decreases, but does not eliminate that risk.

Age is the biggest comorbidity for COVID-19 outcomes. This cannot be emphasised enough.
The following are a few more examples that show the discrepancy in our thinking.
1. We banned smoking in most places, partly to reduce our risk of heart attacks; but that risk is only 2-5 times.

2. We wear seat belts in cars. But not wearing seat belt increases risk of death only 2.5 times (This is US data; the benefit is likely to be lower in India due to lower speed in city traffic)

But COVID-19 raises risk of death 100-330 times for older adults - and most people still do not seem to know about it.

How could this be? That’s because the human mind is not objective or fact-based in its thinking. Perception and hearsay influence our behaviour.

Our ability to comprehend risk, fractions or ratios is not as good as we think. We overestimate many risks, and take extraordinary measures to reduce such risks; e.g. cholesterol and heart attacks, wearing seat belts.

By the same token, we also commonly underestimate certain other risks.

A few risks that are commonly underestimated

1. the risk of death from COVID-19 in older age groups

2. the risk of death or injury while using the road - especially as a pedestrian or a two-wheeler rider

3. the risk of death during pregnancy

In Kerala the overall risk of death on the road is at least 1: 8000 per year, and 1: 1000 per year for getting seriously injured. For more frequent road users, and those in a perpetual state of hurry, it will be much more.

The risk of death due to pregnancy is another risk that is grossly underestimated by society. For India, Maternal Mortality Rate (MMR) is 103 per 100,000, which translates to a risk of death of 1: 970.

The fallacy of believing average values

Many elderly people assume that their risk is low, because the official CFR (case fatality rate) in India is 1.2%.

The published death risk of COVID-19 is relatively low because it is diluted by extremely low rates in younger age groups: 50% of India’s population is under the age of 25, where the COVID death risk is close to zero. Death rates are exponentially higher in older age groups. Thus, it is only when we start looking at individual age groups that we observe the massive difference.

A statistical parallel to this is the following statement: “All Indians are 28 years old”.

This is obviously a wrong statement, but the average age of people in India is indeed 28. Likewise, even though the average case fatality rate in India is 1.2%, that does not apply to every age group.

What is to be done to keep older people safe from COVID-19?

Vaccination is an important step. Fortunately, vaccine hesitancy in India is relatively low, and most people in older age groups have received vaccine. We are aware that the high death rates in Hong Kong are driven by the failure to adequately vaccinate older people.

But we need to do more than vaccination to reduce the death rates in older people. We need to focus on measures that reduce the total number of infections specifically in that age group. It is now known that vaccines are not very good at preventing infections, although they consistently reduce death rates.

As the third wave has ebbed in India, older people are frequently seen coming without masks to indoor mass gatherings.

They might think the risk has gone away because they are vaccinated, and many of them believe that the pandemic is over.

Unfortunately, the pandemic behaves in a cyclical pattern, driven by constant adaptation, generating variants that are faster spreading than earlier versions. BA.2, for example, spreads faster than BA.1 sub-lineage of Omicron. With testing rates declining, officially reported numbers will be low. Asymptomatic infections are a feature of the SARS-CoV2 virus, especially the Omicron variant.

A new variant could originate anywhere in the world, and takes less than 6 weeks to cover a whole country that is located far away. We saw that in the case of Omicron already, where it covered 99% of UK’s genomes within just 43 days of its discovery in South Africa.

In contrast to the youngest age groups, every bout of infection in older people carries a significant death risk – even among the vaccinated. Thus, if we can keep the total number of infections down, we can reduce the number of deaths in that age group.

Doesn’t vaccination help?

It is true that vaccination reduces overall death risk. Thus, a vaccinated 80-year-old is better off than an unvaccinated 80-year-old.

But we must not forget that older people had a high baseline risk to start with. In other words, a vaccinated 80-year-old is still far more likely to die from COVID-19 than a vaccinated 25-year-old.

Older people must understand that risk, and take appropriate additional measures to reduce the chance of getting infected.

What about boosters?

From the latest COVID death data from US CDC segregated in three adult age groups above, it is obvious that 2 and 3 dose vaccination are equally effective in minimising the death rate, especially in ages below 65.

The dotted blue line and solid blue line represent 2 dose and 3 dose vaccination respectively. Both the lines are located close together at the zero line in the 18-49 and 50-64 age groups. The black line represents unvaccinated people in each age group.

However, in the elderly segment (>65), there is a marginal difference in death rates between those who got booster (2.1 out of 100,000) and those who got 2 doses (9 out of 100,000), compared to unvaccinated (57 out of 100,000). It is helpful to note that these rates are out of 100,000. They are shown amplified on a graph. Therefore, the actual difference between 2 and 3 dose groups is extremely small.

These are based on mRNA vaccines; we do not have data on the outcomes following third dose administration in India. People over 60 have been recommended to receive a 3^rd dose in India.

10 practical measures specifically for older people:

1) Stay away from indoor mass gatherings to the extent possible.

2) Stick to outdoors while meeting people or exercising. If absolutely required to be indoors along with strangers, wear an N95 mask with a good fit, taking extra care not to lower it while talking.

3) If still unvaccinated, it is important to complete the vaccination schedule. This will reduce (but not eliminate) death risk in the event of an infection. To further reduce death risk, one needs to work on reducing the chance of picking up infections.

4) During crowded social gatherings indoors, seniors can be gently encouraged to step outside with people of interest – for instance, if they want to have a longer conversation with someone they just met indoors after a long time.

5) Keep indoor time to the minimum. When people talk indoors, risk of virus-laden aerosols is high. These aerosols, like invisible mist, circulate within closed spaces for hours. The longer we stay, the greater the risk. Even people who were recently vaccinated and boosted have picked up infection after sufficient exposure to such aerosols.

6) While visiting public indoor spaces or using public transport, masks should not be removed.

7) Avoid dining in crowded indoor restaurants. There are enough restaurants with outdoor seating now.

8) Younger adults must recognize the disproportionate risk faced by older people, and refrain from activities that could put them in danger. Whenever events are organized, making it safe for seniors must must be given top priority.

9) Younger people must remember to wear masks while being around seniors from outside their own social bubble, particularly indoors.

10) Extra caution to be followed in dwellings where seniors live as a community

These precautions are not to be misinterpreted as “being scared”. There is no need to ridicule someone because they are cautious about their health. We don’t wear seat belts because we are “scared” - but because we are intelligent.

Further reading

Europe CDC Report on increasing deaths in the elderly from Omicron in multiple countries

US CDC data on COVID death by age groups

Risk of cardiovascular mortality from hyperlipidemia, Circulation, 2018

Effect of boosters on death rates in adults by age groups: US CDC data

All-cause mortality during the COVID-19 pandemic in Chennai, India Lancet Dec 22, 2021

Age is the biggest comorbidity. Plos One, Mc Padden

Dr Rajeev Jayadevan MD (Vellore), DNB, MRCP(UK),
American Board Certification in Medicine (New York)
American Board Certification in Gastroenterology (New York)
Co-Chairman, National IMA COVID Task Force
Past President, Indian Medical Association, Cochin