April 22, 2020

expert reaction to paper commenting on COVID-19 risk in people aged 60 to 69

Research, published in the Journal of the Royal Society of Medicine, reports on COVID-19 risk in people aged 60 to 69.

Dr Andrew Freedman, Reader in Infectious Diseases and Honorary Consultant Physician, Cardiff University School of Medicine, said:

“It is very clear that increasing age is a major risk factor for developing severe complications and death from COVID-19.  Other factors, including various co-morbidities are also important and these are more common in older people.  The authors of this article have reviewed the published literature and guidance relating to this.  They question whether the UK’s age cut-off of 70, above which people have been advised to self isolate is too high, given that those aged 60 to 69 are also at substantially increased risk.

“They suggest quite reasonably that those aged between 60 and 69 should decide for themselves whether to take extra precautions to reduce their risk of catching COVID-19.  Although not specifically discussed in this article, this does perhaps raise the question of whether healthcare workers in that age group should be shielded from front line care of patients with COVID-19, particularly if they have additional risk factors.”

Dr Tom Wingfield, Senior Clinical Lecturer and Honorary Consultant Physician, Liverpool School of Tropical Medicine, said:

“Older people and those with pre-existing illnesses are at higher risk of severe disease and death from Covid-19.  Illnesses that predispose to this higher risk include chronic lung disease, ischaemic heart disease, hypertension, or diabetes, all of which are found at higher rates in older people.  But above what age does this risk start to increase?

“Tasnime Osama and colleagues’ article in the Journal of the Royal Society of Medicine raises an important point related to age and Covid-19 risk.  Much of the evidence we have suggests that people aged over 60 – and especially those aged over 65 – years old are at significantly higher risk of severe disease, requiring respiratory support, and death from Covid-19 than younger age groups.  Indeed, the World Health Organisation (WHO) and United States Centre for Disease Control and Prevention (US CDC) class people over 60 and 65 years old respectively as being at highest risk.

“It would be helpful to see what evidence was used to inform the UK government’s decision to define people over 70 years old as a high risk group rather than using a lower age threshold such as 60 or 65 years old.  This is a really important issue for the general public when we consider that more than 7 million people in the UK are aged between 60 and 69 years old.

“In addition to the general public, it is also vital that carers and key workers who are aged over 60, including those returning from retirement to work in the NHS and other social care settings, are provided with accurate information to be able to make informed decisions about minimizing their own risk from Covid-19.”

Dr James Gill, Honorary Clinical Lecturer, Warwick Medical School, and Locum GP, said:

“Currently we consider patients of 70yrs+ to be at the greatest risk, with mortality in this age group from Covid-19 at 22.8%, hence why in the UK this age group is currently being asked to isolate.  Oddly, this is not in line with WHO where isolation recommendations are extended to included others aged 60yrs+.

“One of the benefits of extending the isolation recommendation would be further reduction in pressure on the NHS ITU resources, as rightly the paper highlights that the brunt of the mortality from COVID-19 is seen in the age group of 65yrs+, with 85% of COVID related deaths in this group.  These mortality statistics also line up with data from China where 80% of COVID-19 related deaths where in patients older than 60yrs.

“The risk of mortality from COVID-19 in the 60-69 yrs age group remains substantial, compared to younger members of the population, however it must be acknowledged people in their 60s have a mortality risk 6x lower than those 70yrs and older.  Thus whilst it may be reasonable to question whether measures should be extended to those in the 60-70yrs group, this should not cause significant concern for those people.  A degree of pragmatism can certainly be practiced with regard to the recommendations from this paper – if a person older than 60 is already furloughed from work, then there is no significant disadvantage to personally implementing a more stringent approach to social distancing and self isolation.  Conversely if a person is still required to attend work, then a discussion with their employer to assess if there are additional ways that their exposure could be reduced further would be seen by many as a reasonable conversation to have.”

Prof Arne Akbar, President of the British Society for Immunology, said:

“This commentary paper offers the authors’ point of view on the current UK guidelines regarding age and risk of severe disease from COVID-19.

“As we get older, so do our immune systems, which results in them becoming slower and less effective at fighting off infections that we have previously come across.  In addition, our capacity to respond to new infections is also decreased.  We have witnessed evidence of this in the current Coronavirus pandemic, with the number of fatalities significantly increasing in older age groups.  Older people are also more likely to have other health conditions, such as heart disease or diabetes, which again can affect how well their immune systems can fight off infection.

“There are many changes to the immune system in older age which contribute to it functioning less optimally. Physical changes to the lungs of older people mean that they have poorer cough strength and reduced functioning of cilia, the fine hairs that line the airways. This results in a decreased ability to clear mucus, which traps infections in the lungs where they can build up. The immune cells, whose job it is to clear infections, also don’t function as well in older people. With Coronavirus infections, what seems to be happening in older patients is that their immune systems are less able to move through the different stages of immune response needed to clear the disease. Instead, they get ‘stuck’ in the early stage of immune response, which results in a bigger build-up of debris in the lungs and more inflammation, leading to more serious symptoms. The immune decline as we get older is not synchronized and some individuals may experience the decline earlier than others. The cut-off point to identify older persons for current Government guidelines is over 70 years of age, but some people may start to have declining immunity a decade earlier. There is currently no rapid and reliable test to identify how quickly the immune system ages in different people.

“For all people, it’s crucial to follow the Government’s current social distancing guidelines to stop the spread of COVID-19. This not only reduces the likelihood that you will contract COVID-19 but also stops the virus spreading to vulnerable people, such as older people, who likely to experience more serious symptoms.  The changes that happen to our immune systems as we get older are not necessary reflected in how healthy we feel – you can be a very fit 65-year-old, but your immune system will not work as well as it did when you were 20.  It’s important that we’re all aware of these changes to our susceptibility to infectious disease and take the appropriate precautions to minimise our chances of encountering Coronavirus.  While sticking to the social distancing guidelines can be tough, it really does make a huge difference to stopping the spread of the SARS-CoV-2 virus and protecting vulnerable people.”

‘Protecting older people from COVID-19: should the United Kingdom start at age 60?’ by Tasnime Osama et al. was published in the Journal of the Royal Society of Medicine at 00:05 UK time on Wednesday 22 April 2020.

DOI: 10.1177/0141076820921107

Declared interests

None received.