COVID-19 is still with us but its focus has shifted with more older people now at risk of death, a situation which has again sparked debate about the coronavirus and ageism, and what is "acceptable loss", writes Medical Brief.
In the US, nearly nine out of 10 COVID-19 deaths are now in people 65 or older, the highest rate since the pandemic began, statistics that make it startlingly clear that more than ever, it is now a plague of the elderly.
From John Felton’s view as the Yellowstone County health officer in Montana, US, the pandemic is not over, as President Joe Biden recently said – rather, it’s just different, affecting mainly seniors, and seriously.
The Washington Post reports that in October, Felton’s team logged six deaths from the virus, many of them among vaccinated people. Their ages: 80s, 60s, 70s, 80s, 90s, 90s. Yellowstone County made the decision early in the crisis to recognise each death individually, and Felton said it was as important as ever to acknowledge the unrelenting toll on a still-vulnerable older generation, while almost everyone else has moved on.
Data from the US Centres for Disease Control & Prevention (CDC) show that more than 300 people are still dying daily, on average, from COVID, most of them 65 or older. While that’s much lower than the 2 000 daily toll at the peak of the Delta wave, it is still roughly two to three times the rate at which people die of flu, renewing debate about what is an “acceptable loss”.
And while older Americans have consistently been the worst hit during the crisis, as evident in the scores of early nursing home deaths, that trend has become more pronounced. The current rate of nine in 10 deaths in people 65 or older is the highest rate ever, shows a Washington Post analysis of CDC data.
Some epidemiologists and demographers predict the trend of older, sicker and poorer people dying at disproportionate rates will continue, raising hard questions about the trade-offs Americans are making in pursuit of normalcy, and at whose expense. The situation mirrors how some other infectious diseases, like malaria and polio, rage in the developing world while they are largely ignored elsewhere.
Ageism attached
Matthew Liao, a professor of bioethics, philosophy and public health at New York University, argued that it is possible to keep the economy open while still aggressively pursuing a national booster campaign and requiring masks in health-care settings and nursing homes, for example. But US leaders have chosen not to do so, he said. That worries him.
“There’s a bit of ageism, so to speak, attached to it,” he said, adding, “People, even if they are older, still have as much claim to live as me.”
In an open letter published in The BMJ, Gregg Gonsalves, an associate professor at the Yale School of Public Health, and about a dozen other experts emphasised that “pandemics do not end with a flip of the switch”.
“Despite the widespread belief that the pandemic is over, death and disruption continue,” they wrote.
CDC director Rochelle Walensky and other officials have justified their pandemic reset by saying that Americans have more tools to fight the coronavirus than they did a year or two ago. This includes not only vaccines, booster shots and rapid tests, but antiviral pills that can be taken at home and have been shown to greatly reduce severe illness and death if taken early.
“We can now prevent almost all of the deaths that are happening,” she said. However, she acknowledged that deaths among the elderly, especially those with multiple chronic conditions, are “a real challenge”.
“An additional infection,” she said, referring to COVID, “is something that may turn something they are able to stably live with to something they are not.”
New ‘normal’
Epidemiologists tend to divide the pandemic into three distinct periods. In the first year, from March 2020 to March 2021, the US experienced about 500 000 deaths. The toll was about the same the next year. In the third year, the nation is on track to lower that count significantly, to between 150 000 and 175 000 deaths, barring a new variant.
That means that coronavirus is likely to rank third as a cause of death this year. By comparison, heart disease and cancer kill roughly 600 000 people each year; accidents, 170 000; stroke, 150 000; and Alzheimer’s, 120 000. Flu, in contrast, kills 12 000 to 52 000.
A recent CDC report on COVID-19 mortality contained more good news, most notably, a rapid drop in deaths from March that led to a relatively stable period from April to September when there were 2 000 to 4 500 deaths weekly.
But the reduced death toll has not been experienced equally among all age groups.
Unlike flu, which affects both the very young and the very old, COVID appears to put mostly older people at higher risk of severe disease and death. The proportion of deaths among those 65 or older has fluctuated from eight out of 10 in the first few months of the pandemic, to a low of six out of 10 when the Delta wave struck in the summer of 2021, to a high of nine out of 10 today.
Last month, people 85 and older represented 41.4% of deaths, those 75 to 84 were 30% of deaths, and those 65 to 74 were 17.5% of deaths. All told, the 65-plus age group accounted for nearly 90% of COVID deaths in the US, despite making up only 16% of the population.
The vulnerability of older people to viruses is neither surprising nor new. The more we age, the more we accumulate scars from previous illness and chronic conditions that put us at higher risk of severe illness.
When it comes to the coronavirus, though, deaths in over 65s fell dramatically after the arrival of the original series of vaccines, as seniors were the most likely to get them. But booster rates for older Americans are now lagging. According to the CDC, 98% of those aged 65 to 74 and 96% of people 75 and over completed an initial two-shot course. Those rates fall to 22% and 25%, respectively, for the new Omicron-specific booster.
To minimise further loss of life ahead of a possible winter surge, the government is launching a six-week push to increase booster uptake in seniors and other groups that have been disproportionately affected.
The issue of age and the pandemic has been a source of tension throughout the pandemic.
When hospitals were hit with a crush of patients in 2020, some of the debates about allocating scarce resources centred on age. In documents drafted by some medical institutions, “stage of life”, a proxy for age, was sometimes recommended to be used as a tiebreaker in decisions about who should get a ventilator or a bed.
A number of experts, including Liao, expressed discomfort with such rankings. “I really disagree with that view,” he said. “You can imagine a 70-year-old who can do everything — can enjoy friendship, read books and go to movies.”
While some fault COVID-19 policies for not doing enough to protect the elderly, others criticise age-based policies implemented elsewhere. In the UK, for example, a matrix of recommendations based on age left some seniors feeling they were being discriminated against. Even as stores and restaurants began to open in the summer of 2020, the National Health Service still advised people 70 and older to stay home or “shield.”
Now, even one of the most recognisable seniors during the pandemic, Anthony Fauci, the National Institutes of Health scientist who is 81, no longer wears a face covering in many public appearances.
The decision to forgo masks horrified Andrew Noymer, a public health professor at the University of California at Irvine. “The message is ‘don’t bother masking’,” he said. “We have given up, and the fact we’ve given up means we don’t care about a certain amount of deaths.”
Noymer, who studies COVID-19 mortality, said the notion that we can prevent almost all deaths given the pullback of mitigation policies is disingenuous.
“I don’t think they are being totally candid about the number of deaths the country will face,” he said of US officials. “I think it is bleak, and I am trying to steel myself for the winter to come.”
Meanwhile, here in South Africa, while the pandemic remains with us, albeit under control, there is another matter of concern, reports The Citizen.
The issue around chronic symptoms needs to be given attention, says Professor Mosa Moshabela, dean of Nursing and Public Health at the University of KwaZulu-Natal (UKZN). The country’s first COVID case was recorded in March 2020, and while the statistics of people testing positive increased dramatically, as did numbers of deaths, less has been said recently about the number of positive case.
But, said Moshabela, there people who have had COVID, both knowingly and unknowingly, who are now suffering the consequences thereof.
“Some of those most common chronic symptoms include memory loss, shortness of breath, tiredness and lack of strength, and in some cases that can lead to disability.
“While we have the pandemic under control, thanks to the lessons and experiences learnt, we need to pay serious attention to the virus’ consequences.”
Testing remains important, he added, but because people believe infection rates are down and the seriousness of infections has diminished, testing levels have also declined.
“We appeal to people to use the self-testing kit that has been approved by the South African Health Products Regulatory Authority (SAHPRA),” he advised.
He said COVID subvariants were still being detected, and were trying to evolve, “but they have been circulating at low levels”.
There had, in recent weeks, been a slight increase in COVID cases, but this was erratic, said Dr Angelique Coetzee, former head of the South African Medical Association (SAMA).
“For example, this week we have not seen a lot of positive cases in comparison with last week, so it’s not constant and we do test, but any patient suffering from cold-like symptoms, like a runny nose, sore throat, and a bit of a cough, needs to test, especially if they were vaccinated more than six months ago.
“Also, it’s important to know that if you were vaccinated more than six months ago, your immune system starts to drop so you cannot distinguish between COVID and a cold, flu, and even the diarrhoea we are seeing, so it’s very important to test.”
The problem lies with the long-term consequences regardless of age, Coetzee said, echoing Moshabela’s sentiments.
“Long COVID data show that people are at high risk of cardiovascular symptoms within a year after having been infected, as well as an increase in diabetes and neurological symptoms.”
See more from MedicalBrief archives:
One in every eight adults likely infected with long COVID, large study finds
Repeat COVID infections riskier than first bout – US study
Health minister’s advisers recommend more research on long COVID after study
COVID-19 reinfection twice as likely in the unvaccinated — CDC study