Why isolating older population from Covid would do more harm than good

An idea is gaining traction among some economists and scholars to deal with the pandemic in America: Isolate and lock down older Americans, possibly until there is a vaccine. Everyone else gets to go back to work and regain something resembling normalcy.

Some proponents call it “shielding” the eldest, usually defined as those 65 and older. Others prefer terms like “targeting” or “cocooning.” One Georgia freeway sign said: “Isolate the Elderly.” I’d label this pandemic proposal wrong, deeply wrong.

Simply put, Orwellian age-based segregation will undermine the economy’s vitality, betray society’s values and won’t contain the virus.

“Even if we made the value decision that we’re going to isolate people who are over 60, 65, 70 — you pick — out of the economy, out of the labor force for their own sake and all the rest of our sakes, it won’t work,” says Ruth Finkelstein, executive director of the Brookdale Center for Healthy Aging at Hunter College and a Next Avenue Influencer in Aging.

The targeting idea got widespread attention after four MIT economists wrote a paper recommending it (“Optimal Targeted Lockdowns in a Multi-Group SIR Model”) and publishing a related article in Time. SIR, incidentally, is not said with love: it stands for Susceptible, Infected and Recovered; a basic epidemiological model.

The MIT economists — Daron Acemoglu, Victor Chernozhukov, Iván Werning and Michael D. Whinston — calculated what they determined to be the costs and benefits of different strategies for limiting the spread of COVID-19 while encouraging growth in gross domestic product (GDP). They argue the most efficient policy is for the government to focus its scarce resources on lockdown policies targeted at those 65 and older (roughly 50 million people), since they’re more vulnerable to dying from COVID-19.

“Because those over 65 years of age have around 60 times the mortality rate of those ages 20 to 49, lockdowns on the elderly as a protective measure can be very effective in reducing deaths,” they wrote.

Their paper didn’t elaborate on how exactly the isolation strategy would work. But they believe in taking steps to protect the vulnerable in nursing homes and other residential care facilities. And they advocate for the creation of an Elder Care Corps to provide a few hours of support a week for older Americans who live alone or with others their age.

Problems with isolating older adults until a vaccine arrives

I don’t find the age-segregation solution convincing.

A major problem with targeting is that it’s based on a basic fallacy about aging: that older people are a homogeneous cohort. They aren’t.

“There is extraordinary heterogeneity across the older population,” wrote Nora Super, senior director of the Milken Center for the Future of Aging and James Appleby, CEO of the Gerontological Society of America. “As we age, we become more different. Not more alike.”

Roughly 39% of men age 65 to 69 and 30% of women that age are in the workforce, not at home and retired, according to the Urban Institute. Boomers — ages 55 to 73 — account for more than 40% of small-business owners. They also spend half of all money Americans shell out for groceries, cosmetics, cleaning products and the like.

In other words, isolate older Americans and “the economy hits the skids,” warns Joseph Coughlin, director of the Massachusetts Institute of Technology AgeLab, author of “The Longevity Economy: Inside the World’s Fastest Growing, Most Misunderstood Market” and a Next Avenue Influencer in Aging.

Adds Eugene Steuerle, an economist at the Urban Institute: “Treating people 65+ as monolithic is questionable.”

The effect of isolation on older adults’ health

Isolation of older adults can lead to worsened health for them, too.

Aida Suárez-González, of the UCL Institute of Neurology in London, just published a paper noting disturbing findings of people with dementia in an April 2020 Italian Cognitive Disorders Centre survey of 139 patients.

In their first month of lockdown, 54% of respondents reported worsening or onset of agitation, apathy and depression. And, she noted, an Alzheimer’s Society survey in the U.K. showed that 79% of the 128 care homes surveyed said lack of social contact was believed to be causing a deterioration in the health and well-being of their residents with dementia.

Recently, the death certificates of three Minnesotans in their 90s listed “social isolation” as a cause of death or contributing factor, according to Twincities.com.

The American Psychological Association has said we need to “encourage social distancing, not social isolation.”

Making sacrifices, within reason

Another troubling issue: What kind of society lets younger generations keep their freedoms while denying choice to an older generation who is, on average, living healthier and longer lives than in the past?

That isn’t to say the older generation isn’t willing to make sacrifices in the pandemic.

“If it were a question of being quarantined for a bit longer so that they [younger people] could go about their business, I would do it,” says Alicia Munnell, 77, an economist and executive director of the Center for Retirement Research at Boston College, who’s been sheltering in place with her husband, son and his family in Vermont. “I wouldn’t like it. But I would do it.”

So would I, and I bet most of my peers would too. (I’m 66.)

In fact, an April 2020 survey of Americans 70 and older from NORC at the University of Chicago found that 83% of them said they’re prepared to self-isolate for several months if necessary, to stay healthy and safe and protect others.

Who wouldn’t shelter in place for slightly longer if it meant younger people could launch their careers and start families? But for an uncertain length of time that could easily extend for years during the hunt for safe, mass vaccinations? Not a chance.

That’s why I think the targeting idea is a non-starter politically in the U.S.

Older adults and younger adults

Policy prescriptions based on age and vulnerability to COVID-19 are reductionist in another way.

While at least 40% of coronavirus deaths have been in nursing homes, only about 4% of those 65 and older live in nursing homes and other residential care settings. And the COVID-19 death rate of 63 per 100,000 for those ages 65 to 74 is much less than 481 per 100,000 for people 85 and older.

Even more important, many young Americans live with the same underlying health conditions that put them at risk to the coronavirus as older ones, including diabetes, asthma and obesity. The recent spike in coronavirus cases in Florida, Texas and elsewhere has largely been driven by young adults partying and gathering in large crowds. Their fatality rate from the virus will be lower than older adults, but it won’t be zero, either. (Nor is it clear if there will be long-term effects on their health.)

The connection to the early days of HIV/AIDS

Finkelstein drew a parallel to what she saw when she was a grad student deeply involved in the fight against HIV/AIDS. Back then, the focus was on what were called the four “H’s”: homosexuals, Haitians, heroin users and hemophiliacs. She’d point out that the early HIV/AIDS studies were mainly of white, college-educated gay men and she kept saying: ‘No, people of color are at risk, but you aren’t including them.’

“I started to go absolutely bananas,” Finkelstein says. “The virus was disproportionately affecting people of color.” Of course, we now know that people of color are at far greater risk to HIV/AIDS than whites.

“Now, carry this forward” to the coronavirus, Finkelstein says. She believes not enough attention is being paid to its racial disparities. The focus on age alone underestimates the impact of disparities in health and vulnerability to COVID-19 among people of color.

“The degree of enhanced risk bound only on age is severely overstated in the data. We’re so preoccupied to find the vector, the villain, the victim, who to blame?” says Finkelstein. “We need entrepreneurs, we need startups, we need businesses to open. But we won’t do it by isolating any one group.”

Vice President Mike Pence recently said: “It’s a good time to steer clear of senior citizens.”

What would work better

But the truth is, we’re going to be living with this virus for years, at least until mass vaccination becomes practical, and that’s before considering prospects for future pandemics in the global economy. (Some public health officials and scientists fear a coronavirus vaccine might not be fully effective for older Americans with weakened immune systems.)

What would work to attack the coronavirus is to embrace investing in what Finkelstein calls “universal precautions.” That could include creating widely installed air filtration systems at work; safer public transit options and the ability for Americans to do as many jobs as possible remotely.

When telework isn’t an option — think meatpacking and groceries and hospitals — employers will need to follow stringent safety solutions. Deep-seated inequities in access to good health care will need to be erased, too.

To be sure, investments like these aren’t cheap or easy. But they build off, and help create, a strong societal foundation.

As 79-year-old Dr. Anthony Fauci, director of the National Institute for Allergy and Infectious Diseases, recently remarked: “We are all in it together. And the only way we’re going to end it is by ending it together.”

Young and old alike — together.

https://www.marketwatch.com/story/why-isolating-the-older-population-wont-work-and-would-do-more-harm-than-good-2020-07-15

Russia ‘could have Covid-19 vaccine by September’, official claims

A top Russian official said his country could roll out a vaccine against Covid-19 as soon as September, while denying accusations that hackers working for the country’s intelligence agency tried to steal sensitive data from rival researchers in Britain , the US and Canada 

“

Russia may be one of the first to produce a vaccine against the backdrop of the billions that are being invested in the US and all the pharma companies working on it,” said Kirill Dmitriev, the chief executive of the government-backed Russian Direct Investment Fund (RDIF), which is financing one of the country’s effort to devise a vaccine.

President

Vladimir Putin has made finding a vaccine a top priority. Russia has recorded more than 750,000 Covid-19 cases, making it the fourth most-affected country in the world. In Russia’s race to be the first to find a vaccine against Covid-19, it’s taking an approach that would be shunned in other countries, claiming it will know in just three months of trials whether its leading candidate works.

Dmitriev said Russia had no need to steal information from rival vaccine developers because it had already  

signed a deal with AstraZeneca to manufacture the University of Oxford’s Covid-19 vaccine

at R-Pharm, one of the largest pharmaceutical companies in Russia. He said AstraZeneca is transferring the entire technological process and all ingredients for the full reproduction of the vaccine in Russia.

“Everything that is needed to produce the British vaccine has already been transferred to R-Pharm,” he said. “AstraZeneca has already signed commitments to transfer all production of the British vaccine to R-Pharm.”

“We don’t see a history of innovative vaccines being developed in Russia that win approval” in major markets like the US, Japan and western Europe, he said. “Russia is not a major producer of export quality drugs or biologics.”

The US, western Europe and  China have all set up research programmes and supply chains for Covid-19 vaccine production. While the negotiations with AstraZeneca offer Russia the chance for doses of the Oxford vaccine if it proves successful, the global battle to secure supplies could leave Russia struggling to access other potentially successful vaccines, increasing pressure to advance its own programme.

Dmitriev said he is so confident in Russia’s leading vaccine candidate that he has taken it himself and had his whole family vaccinated, including his parents, who are in their seventies. The vaccine, financed by RDIF and developed by the state-backed Gamaleya Institute in Moscow, has completed a phase 1 trial in 50 people, all of whom are members of the Russian military. The institute has not published results.

https://www.scmp.com/news/world/russia-central-asia/article/3093786/coronavirus-russia-could-have-covid-19-vaccine

Do HVAC Air Filters Protect Against Coronavirus Indoors? It Depends

Heating, ventilation and air conditioning (HVAC) systems have never been the hottest conference or cocktail hour topic. “I’ve never gotten more than 15 people in a room that wanted to talk about ventilation,” says Theresa Pistochini, the engineering manager at the Western Cooling Efficiency Center at the University of California, Davis. But during a pandemic, her webinars draw hundreds of viewers.

The sudden ventilation fascination comes from businesses and schools trying to operate while keeping indoor air as virus-free as possible. The American Society of Heating, Refrigerating and Air-Conditioning Engineers, or ASHRAE, weighed in on this issue by saying that air filtration systems can reduce how much of the coronavirus is indoors. You can browse a range of new guides to the best and worst air purifiers on the market. But when it comes to a new filter actually catching viral particles, a lot more needs to happen besides swapping a dirty screen for a clean one.

New Understanding Means New Interventions

Interest in HVAC systems is due in part to changing ideas about how the virus reaches new people. If the coronavirus was only dispersed by big spit droplets, no one would be talking about the efficacy of ventilation systems, says Brent Stephens, an indoor air pollution and filtration researcher at the Illinois Institute of Technology. Those globules would hit the ground long before a fan would suck them into a filter. But more scientists are agreeing that the virus moves through smaller particles, too — ones that float through the air and can get trapped by some filtration systems.

The question of how the virus spreads is complicated by conflicting definitions of “droplet” in the research community. When aerosol scientists talk about droplets, they mean pretty big globs. “Those are like, ballistic droplets that land in your eye,” Stephens says. The particle size the WHO and CDC calls a droplet — a fleck 5 micrometers across — is small enough that Stephens and his colleagues consider those specks capable of floating through the air. Though the WHO has yet to agree with the hundreds of other scientists that say the coronavirus spreads via smaller particles, what the organization considers a “droplet” already qualifies as an airborne fleck in the eyes of other professionals.

The good news is that there are filters that trap some of the tiniest virus-carrying spit bits. One variety called a MERV-13 filter takes on the majority of particles between 0.3 and 1 micrometers in size. A more restrictive option, the HEPA filter, catches 99.97 percent of 0.3 micrometer particles. Offices, schools and restaurants may opt to install these filters in ventilation systems.

The Filter Is Only Half The Battle

For the virus-sifting to actually happen, air needs to circulate in a building and bring the floating virus to the filter. Some buildings struggle achieving the right air flow.

Pistochini saw this while studying ventilation in California public school classrooms. She and her team inspected the recently-updated HVAC systems in 104 classrooms across the state and found that 51 percent were installed incorrectly or had faulty filters or fans. Per industry recommendations, state regulations say that every second, seven liters of air need to flow through the room per student. The team calculated that the average classroom only moved about three quarters of the air it should. “We were really surprised we saw the prevalence of problems that we did,” Pistochini says.

Some of these issues might be due to insufficient expertise and oversight. Though the industry association ASHRAE has recommendations on how building ventilation should be maintained, individual state protocols decide how that happens, Pistochini says. In California, the public schools are expected to do their own policing of their HVAC functionality. Installation and maintenance of HVAC systems is also a technical job. Organizations issue certifications to qualified repair people, and there are specific tools required. “Districts need to do this with certified technicians in order to really get it right,” Pistochini says.

She also thinks each classroom should have a carbon dioxide detector installed. Levels of the chemical — which we all exhale — serve as a proxy for how much fresh air moves into the room. If CO2 concentration rises above what state-specified airflow would maintain, then the school building knows it’s time to inspect the HVAC system.

At the end of June, the California legislature introduced a bill that would provide funding for classroom CO2 detectors and inspections of school HVAC systems before reopening. The text is very similar to what Pistochini and her colleagues put on their program website.

Filtering Solo

Buildings too old to keep up with modern air filtration infrastructure might need stand-alone, plug-in units. This could be the case in, say, decades-old and historic college campus classrooms, Stephens says.

Before installing one of these filters, there are a few things to look for on the box. One is that the machine uses a HEPA filter, the more aggressive of the two filter options. The device also needs a Clean Air Delivery Rate. This value shows how much air the system filters per second, depending on the particle size you’re targeting — again, for HEPA filters, that’s 0.3 micrometers. The number also proves a third party vetted the filter, a necessary qualification. “The air cleaner industry is fraught with people selling technologies that don’t really work,” he says. Finally, the filter ought to say what square footage room it can handle.

Freestanding devices can be useful even in environments with an HVAC system, Stephens says. Those building-wide units often cut the fan once the room is at the right temperature — and constant airflow is crucial to the whole filtration concept.

Though Stephens thinks improved air filtration should be a line of defense below social distancing and mask-wearing, he’s helping his campus prepare for improved air purification. And Pistochini adds that improved filtration doesn’t mean schools should open. There are other factors to consider.

But once the pandemic is over, there are still benefits to gain from proper classroom ventilation. Research has shown that attendance records and academic performance drop in poorly-ventilated schools. And if your office has bad airflow, any of its accompanying mental slog might follow you too. “A lot of important decisions are made in board rooms and conference rooms where you have a dense number of people and expect good decisions to be made,” Pistochini says.

Ultimately, Pistochini hopes the need to minimize coronavirus exposure will motivate these school HVAC changes in California. “If this isn’t enough, I don’t know what is.”

https://www.discovermagazine.com/health/do-air-filters-in-hvac-systems-offer-protection-against-coronavirus-indoors

In Smaller Hospitals, COVID-19 Patients At Triple Risk Of Dying – National Study

Research from Boston and around the country finds that critically ill COVID-19 patients are much likelier to survive if they’re treated at bigger hospitals.

The sweeping study just out in the journal JAMA Internal Medicine is the first to look at hospital mortality rates in COVID-19 patients nationwide. It includes detailed data on more than 2,200 patients in 65 hospitals.

“Patients who were admitted to hospitals with fewer than 50 ICU beds— so, smaller hospitals — had a more than threefold higher risk of death than patients admitted to larger hospitals,” says senior author Dr. David Leaf from Harvard Medical School and Brigham and Women’s Hospital. The following are edited excerpts of our conversation.

How would you sum up what you’re reporting in this paper?

We conducted a multi-center study across 65 hospitals in the United States where we collected detailed data on over 2,000 critically ill adult patients with COVID-19. We found that patients had a 35% risk of death within 28 days of ICU admission.

We also identified several independent patient- and hospital-level risk factors for death. Patient-level risk factors included characteristics like older age, being male, obesity and cancer.

On hospital-level risk factors, we found that patients who were admitted to hospitals with fewer than 50 ICU beds — so, smaller hospitals — had a more than threefold higher risk of death than patients admitted to larger hospitals.

We also found that treatments vary dramatically from hospital to hospital, whether we’re talking about medications like hydroxychloroquine or steroids, or certain interventions like proning, which is when you flip a patient onto their belly, which helps with oxygenation.

Many people will hear that statistic about a three-fold higher risk and say, “If I get COVID, I want to make sure I go to a big hospital.” Would you want to temper that reaction with any sort of caveats?

I’m glad you brought that up. We collected very detailed data in this study. We had over 800 data points per patient, each of which was manually chart-reviewed. Thus, with over 2,000 patients we had over a million discrete pieces of data. We adjusted for a very comprehensive set of potential confounders.

Nonetheless, we weren’t able to capture everything imaginable. So, for example, we didn’t have data on doctor and nursing staffing. We didn’t have data on hospital strain. And we didn’t have data on socioeconomic status of patients, which has emerged as an important risk factor in patients with COVID-19. So certainly there could be residual confounding. There could be factors that we didn’t measure that could explain some of these findings.

But would you say that it’s a reasonable takeaway, that it’s probably a better bet to go to a hospital with more than 50 ICU beds?

That’s really tough to answer. Larger hospitals do have more resources. And in settings outside of COVID-19 — for example, if you look at patients who require mechanical ventilation for respiratory failure from due to causes other than COVID-19 —  larger hospitals do seem to have better outcomes.

Could you comment on your finding that race didn’t seem to be correlated with mortality?

We found that Blacks were actually much more represented in our cohort of critically ill patients than they are in the country: About 30% of our population was Black, whereas Blacks only represent about 13% of the US population. Thus, Blacks were over-represented in our cohort of critically ill patients by nearly threefold.

But among patients who were in our study, mortality did not differ according to race, which is similar to findings that were reported in a study from Louisiana that was in the New England Journal of Medicine. If you were Black, you were more likely to be admitted to the hospital or to an ICU, but once you’re already there, you have similar outcomes compared to patients of other races.

How would you say our American mortality statistics are measuring up against other countries’?

It’s really hard to compare studies because different studies have different lengths of follow-up. Some studies only follow patients for a week, and patients often don’t die in the first week. There are also differences in admitting practices across countries, and even within the same country, across hospitals. I would say our mortality numbers are in the same ballpark as what other countries have reported.

Are your findings actionable for medical staffs or families?

We didn’t develop a prognostic scoring system where you plug in the patient’s age and gender and other elements, and it tells you that you have a 90% chance of death or a 10% chance of death, for example. We’ve done that in a subsequent paper that is currently under review.

But I think just having a sense of what the risk factors are for death might be helpful for patients and families in making decisions about how aggressive to be.

Were there any institutional red flags about outlier hospitals that looked really bad?

I can’t get into specific names but the short answer is yes. The risk-adjusted mortality in the study ranged from 7% at the lowest-risk hospital to 80% at the highest-risk hospital. That was one of the key findings of the study, in fact: more than a tenfold change in your risk of death, after having accounted for many of the differences in patient characteristics across hospitals.

So again, doesn’t that mean you really want to go to a bigger hospital if you can?

But you may not have a choice. You may have to just go to the closest hospital.

What’s next?

What we’re really interested in now is identifying treatments that can improve outcomes. Of course, randomized control trials are ongoing and those will always be the gold standard, but randomized controlled trials take a lot of time and they can’t answer every single question.

So, for example, there are randomized controlled trials ongoing for certain drugs, but they’re not specifically looking at critically ill patients; or they may only be enrolling a much smaller number of patients than what we had here, and thus will not have adequate statistical power to assess hard outcomes like mortality.

So we are trying to use our database, which now includes over 5,000 patients, to answer some of these questions about which treatments improve outcomes. We have several papers that are under review that are looking at this.

https://www.wbur.org/commonhealth/2020/07/15/covid-hospital-mortality-death-bigger

Winn-Dixie won’t require customers to wear face masks

While many retailers across the country are requiring customers to wear face masks, Winn-Dixie says they will not be.

The supermarket chain’s website says it is “strongly encouraging” its employees and associates to wear face coverings.  However, Winn-Dixie’s parent company, Southeastern Grocers, will not mandate masks for customers to be able to shop in their stores.

Director of corporate communications Joe Caldwell told FOX 13 News the reason is that it does not want to “cause undue friction between our customers and associates by regulating mask mandates.”

“We are adhering to all local safety mandates within each of our stores and strongly encouraging those who are medically able to wear a face covering to do so,” Caldwell said, adding that the company would strongly encourage state government officials to “lead the way” in creating such mandates.

Publix announced Thursday it will be requiring customers to wear masks while shopping in its stores starting July 21. Other national retailers such as Walmart, Target, and Home Depot are also mandating masks in their stores.

https://www.fox35orlando.com/news/winn-dixie-wont-require-customers-to-wear-face-masks