“Rule 9 of Internal Medicine: Timing is everything, and sometimes time is the cure.”
Phillip K. Peterson (Get Inside Your Doctor’s Head: 10 Commonsense Rules for Making Better Decisions about Medical Care)
Since the last Germ Gem: “COVID-19 and the “P” Words,” the information tsunami continues unabated. Keeping up can be exhausting, but the good news is that as more reliable data accumulates, more confident advice is made possible. Questions that I’m frequently asked are: “What’s the risk to my kids?”; “What about my grandparents?”; and “What about me?” This Germ Gems provides my opinions about these important questions.
Before jumping to the answers, however, let me give you some relevant professional background. Seven years after completing my infectious diseases fellowship at the University of Minnesota Hospital, I moved in 1984 from the university hospital to Hennepin County Medical Center (HCMC), an inner city hospital in Minneapolis. My main academic interest was in infectious diseases in patients with a compromised immune system.
It quickly became obvious to me that infections in organ and bone marrow transplant recipients were no longer the main problems to study. Rather, based on what was known at the time, it appeared that in a general hospital like HCMC, the largest group of immunocompromised patients were elderly adults. Thus for the next 12 years, “infections in the elderly” became a major clinical research focus. (You might find it remarkable that within two years I became recognized as a world authority on the topic. This was due, in no small part, to the fact that I was one of only two infectious diseases specialists studying the problem—perhaps, unsurprisingly, the elderly had been largely neglected.) Over the course of those 12 years, I learned a lot about the impact of age on the immune system and about the aging process itself. It is with this perspective that I’ve watched the data come in regarding COVID-19 in the elderly, as well as parallels at the other end of the age spectrum.
As you probably already suspect, the age of a patient is often the most important clinical determinant of what infections to consider in making a diagnosis, as well as in offering a prognosis (outcome).
COVID-19 in the elderly. First, let me emphasize that for reliable information for virtually every aspect of the COVID-19 pandemic, the Center for Disease Control and Prevention (CDC) website (cdc.gov/coronavirus/2019) is outstanding, and its treatment of the topic of “COVID-19 in the elderly” is no exception. If you are elderly or have a loved one who is, I urge you to visit its website. (BTW, my definition of “elderly”—anyone older than I am— differs from the conventional definition: anyone equal to or greater than 65-years-of-age.)
As expected the elderly, especially those with underlying medical conditions, such as heart disease, lung disease, and diabetes mellitus, are at a significantly greater risk of acquiring COVID-19 and of dying from it.
The increased COVID-19-related mortality of the elderly in China, where the pandemic emerged, has been corroborated in Italy, the current epicenter of the pandemic in Europe. According to data from the Italian National Health Institute, the spectrum of mortality by age ranges from 0% in the 0-29 age group to 19% in those over 90-years of age (a whopping 88% of the deceased are age 70+). Interestingly, it appears that the main reason that Italy is the European hotspot of the pandemic is they have the laudable, but now unfortunate, honor of being home to a large elderly population. (Italy has the second-oldest population in the world and its young tend to mingle more often with elderly loved ones.)
Another important fact recently reported by the Italian national health authority is that more than 99% of their coronavirus fatalities were people who suffered from previous medical conditions. Moreover, the Rome-based institute found that just three of the fatalities, or 0.8% of the total, had no previous chronic medical conditions.
The United States appears to be no different. According to a March 17 article in the Washington Post, which has tracked every known death in the U.S., 85% of coronavirus deaths were in people older than 60, and 45% of those were older than 80. And the underlying health conditions mentioned earlier increased the risk of death.
So how do these data translate to giving advice to elderly people about COVID-19 and to those who have grandparents in this age group? So far, it seems that they need to follow the same recommendations from the CDC for everyone else but to take them even more seriously. (Again, please visit the CDC’s website.) Similar guidelines are provided in other resources, and they were touched upon in previous Germ Gems.
It appears that COVID-19 in elderly people presents with the same symptoms as in younger people: dry cough, fever and/or shortness of breath. But from my clinical experience at HCMC, I suspect that these classical symptoms of pneumonia may not manifest as early in the course of their infection. A change in mentation is often the first sign of any serious infection in the elderly. (“Grandpa just isn’t himself today.”). So play very close attention for any evidence of confusion, changed behavior, increased sleepiness, etc.
I mentioned earlier that the elderly are considered immunocompromised (due to a phenomenon called immunosenescence), and this may play a role in their increased risk of fatal COVID-19. But our experience at HCMC suggests that many may have a more subtle or non-classical clinical presentation resulting in delayed diagnosis and treatment. As more data are collected outside of China and Italy a more detailed assessment of COVID-19 in the elderly hopefully will emerge.
An additional difficulty that confounds caring for elderly people is that a large majority of people 65-years-of-age or older are totally healthy and have an immune system just as robust as that of 30-year-olds. Sadly, however, we don’t yet have biomarkers of physiological age and thus rely on chronological age (65-years-of-age or greater) that was set by the Social Security Act in 1935 for retirement benefits.
In a March 16 Washington Post article, “This disease is a double blow for grandparents,” Victoria Brown points out the dilemma of many grandparents. They frequently serve as caregivers or baby sitters for their grandchildren. Yet they are told to avoid children. Also, a problem with social distancing, like self-quarantining, is that for the elderly many are already struggling with loneliness. Such distancing exacerbates this condition.
COVID-19 in children. From the data reported so far, it appears that the good news for children is that they are less susceptible to COVID-19, and when infected, the disease is less severe. A report “SARS-CoV-2 Infection in Children” from China, published in the New England of Medicine on March 18, described only a single death in 171 confirmed cases treated at Wuhan Children’s Hospital. And of the three children who required intensive care support, all had coexisting medical conditions.
In a March 17 article in MedPage Today, analysis of 2,143 pediatric cases found that most were mild (50.9%) or moderate (38.8%), and only 5.9% were severe. Not surprisingly, however, is that infants (<1 year) were at greater risk of severe or critical illness. From experience with most other infections an increased risk of severe disease at both ends of the age spectrum is to be expected. And this is often explained by the fact that the immune system of infants isn’t fully developed. (As one of my professors at Columbia University College of Physicians and Surgeons said: “The study of geriatrics begins in pediatrics.”)
While the good news is that severe disease is less likely in children, the bad news is that kids seem more likely to have asymptomatic infections and spread SARS-CoV-2. The data on the incidence of asymptomatic infection and transmissibility of the virus by asymptomatic patients, however, is under investigation, as is the nature of disease severity in children, both of which remain somewhat of a mystery.
In addition to guidelines from the CDC website already mentioned, I highly recommend a March 12 article by Lauren Perry, based on her interview of Thomas Perry, M.D., Ph.D., a Yale pediatric infectious diseases specialist: “Kids and COVID-19: What Parents Should Know.”
COVID-19 in the unborn. As you likely know, some viral infections in pregnant women pose a major threat to the fetus, for example, rubella and cytomegalovirus. Based on very limited data from China it appears this may not be so with SARS-CoV-2. Obviously, as more experience is gained a much better understanding of this aspect of COVID-19 will emerge.
COVID-19 and everyone else. For readers who aren’t in the over 65-years-of-age risk group or don’t have children to worry about, you’re probably wondering: “What about me?” And “What should I be concerned about?”
In a March 19 article in the New York Times (“Younger Adults Make Up Big Portion of Coronavirus Hospitalizations”), Pam Belluck provides data from a CDC report on the first roughly 2,500 cases in the U.S. Of the 508 patients who were hospitalized, 38% were between 20 and 54. And nearly half of the 121 patients who were admitted to intensive care units were adults under 65. Of the 44 people whose deaths were recorded in the CDC report, nine were adults age 20 to 64. While these numbers seem scary, you should know we don’t know yet how many of these had underlying medical conditions.
Also, according to the CDC, the first preliminary description of outcomes among patients with COVID-19 in the United States indicates that the fatality in these patients was highest in persons aged ≥ 85, ranging from 10% to 27%, followed by 3% to 11% among persons aged 65–84 years, 1% to 3% among persons aged 55-64 years, <1% among persons aged 20–54 years, but no fatalities among persons aged ≤19 years
So for millennials and those in Gen X and Z, don’t be cavalier about COVID-19. You need to follow the same protective measures provided by the CDC. And if you develop a dry cough, fever, and/or shortness of breath, call your doctor. If you are diagnosed with COVID-19, you are highly likely to recover completely.
Bottom Line. Take a deep breath. Even though we are in many ways in uncharted territory with COVID-19, we can be grateful for the enormous dedication and skills of many scientists, public health workers, and physicians who have stepped up to the plate. It is absolutely clear, however, that panic is not indicated nor is it at all helpful. Predictions are often wrong. (I’m unaware of anyone who predicted this past fall that COVID-19 would emerge as a global threat, and I suspect you know of no one who correctly predicted last November where the stock market would be this year.) That said, I nonetheless predict the pandemic will eventually subside, and that we will learn a lot beforehand.
When faced with difficult decisions, I often turn to my wife who incidentally came up with the idea of my starting Germ Gems. She not only has her share of unsubstantiated “old wife tales,” but she has a lot of what’s needed now: commonsense. Here is the advice she gives to her friends and family (including me). “Eat well; get adequate rest; go outside and walk for at least an hour a day; and limit your news intake to once a day. If you have symptoms that could be from a common cold, the flu, or COVID-19, call your doctor. Follow their instructions. Also buy fresh flowers for your house. It will lift your spirits and cost less than an hour with a therapist!” (She’s not a health professional, but I agree—and I am going for a walk with her now.)