Protecting older people from COVID-19: should the United Kingdom start at age 60?

On 11 March 2020, the World Health Organization declared the COVID-19 outbreak a pandemic due to the rapid spread of the infection.[1] With a vaccine at least 12 to 18 months away, and no effective drug treatment currently available,[2] the options for controlling the pandemic remain limited.

The virus causing COVID-19, SARS-CoV-2, is primarily spread through droplets and is highly contagious. A lack of tests to identify and isolate cases, insufficient personal protective equipment and a delayed lockdown, implemented only on 23 March 2020, will facilitate COVID-19 spread, thereby increasing morbidity and mortality in the UK.

The UK Government has stated that those aged 70 years and older are at an increased risk of severe illness from COVID-19.[3] To reduce mortality from COVID-19 and to avoid overwhelming the National Health Service, prevention efforts, implemented in a timely manner, are essential. One step the government has taken to reduce the risk to individuals and the National Health Service is to advise people aged 70 years and over to ‘isolate’.[3]

Other countries have adopted different age thresholds for isolation and the advice from the World Health Organization is that people over the age of 60 years are at a significantly greater risk of COVID-19.[4] This includes a heightened risk of severe illness, hospitalisation, intensive care unit admission and death. Should the UK’s cut-off of 70 years for isolation, therefore, be lowered?

Although SARS-CoV-2 infects individuals of all ages, the World Health Organization states that two groups are at a higher risk of severe COVID-19 disease.[4] While the severity of the disease increases from the age of 40 years, those above the age of 60 years and those with underlying medical conditions including, but not limited to, diabetes, cardiovascular diseases, chronic respiratory diseases and cancers are at the highest risk.[4] Despite the highest case fatality rates being observed in those above the age of 70 years, a case fatality rate of 3.6% in the 60–69 years age group is still substantial.[5] Overall, intensive care is required in about 5% of people with COVID-19 infections;[6] patients requiring critical care, such as respiratory support, are usually older with a median age of 60 years.[6]

Furthermore, non-communicable diseases are common in older people.[7] In the UK, around 52.8% of those in the 65–74 years age group have two or more medical conditions.[8] In those above the age of 65 years, arthritis, hypertension, respiratory disease, cancer and diabetes are found in 62.6%, 55.9%, 24.4%, 23.7% and 21.6%, respectively.[8] The risk of COVID-19-related complications and deaths increases in those with underlying health issues;[4,5] 40% of cases requiring critical care have co-morbidities.[6] While the death rate in those with no reported co-morbidities is 0.9%, the death rate is 10.5%, 7.3% and 6.3% in those with cardiovascular disease, diabetes and chronic respiratory disease, respectively.[5]

The US Centers for Disease Control and Prevention reports that 80% of COVID-19-related deaths are in those aged 65 years and over.[9] Furthermore, the Centers for Disease Control and Prevention reports that 31% of cases, 45% of hospitalisations and 53% of intensive care unit admissions occurred in those aged 65 years and older,[9] in line with evidence from China where 80% of deaths were in those above the age of 60 years.[10] In the US, those in the 65–84 years age group accounted for 25% of cases, 46% of intensive care unit admissions and 46% of deaths.[9] In Italy, a country of similar economic and social development to the UK, the case fatality rate was 7.2%, compared to China’s case fatality rate of 2.3%.[11] However, both Italy and China have similar case fatality rates for those aged 60–69 years (3.5% in Italy and 3.6% in China).[11] Other western countries, including Switzerland and France, encourage those aged 65 and older to enforce strict public health measures due to their increased risk of severe illness and death from COVID-19.

About 7.3 million people aged between 60 and 69 years live in the UK.[12] While this group is at a lower risk of severe illness when compared to those aged 70 years and older, their risk is still considerable. Hence, the UK’s current policy places these 7.3 million individuals at increased risk of severe illness and death. The UK’s policy is also at variance with the World Health Organization, which states that those above the age of 60 years are at the highest risk,[4] requiring additional preventive measures.

National and global spread of COVID-19 is accelerating. To reduce COVID-19-related hospitalisations, intensive care unit admissions and deaths, we recommend that those aged between 60 and 69 years are particularly stringent when implementing public health measures such as social distancing and personal hygiene. In the absence of government guidance, people in this group can make their own informed decisions on how to minimise their risks of COVID-19 infection. This can include isolating themselves in a similar manner to that recommended by the UK government for people aged 70 years and over.