What do you think of the idea of “focused protection” or “shielding” the vulnerable so that everyone else can get on with normal life?

Clinical Symptoms Infection and Spread

A: We *wish* it were this easy, but sadly it’s not.

While this approach sounds appealing on the surface, the deeper you dig the more the argument collapses in on itself.

Let me explain. No, there is too much. Let me sum up:

• The death and hospitalization toll even in under 65s would be staggering

• No consideration of waning immunity and re-infection

• No mention of impact of “Long Covid” for millions infected

• Cordoning off of a large percentage of the population is not feasible

• False dichotomy between lockdown and “back to normal”

• We never reached “natural” immunity to infections such as cholera, yellow fever, polio, measles, TB, and the plague—these were brought under control through public health measures and ultimately vaccines.

The stated goal of the “focused protection” policy is to protect those who are vulnerable by “building up natural immunity” among the rest of the population.

• Let’s pretend there is a magic world where it is possible to put the 54 million Americans aged 65 and over in a protective bubble without any interaction with younger people. Next let’s assume that to achieve a high level of population immunity required to protect those vulnerable later on (since part of the population would stay susceptible), you would need 80% of those under age 65 to be infected.

Let’s remember that while risk of death from COVID-19 rises steeply with age, there are still many under 65s who die of the disease. In fact, at current age-specific infection fatality rates (IFRs), the expected number of deaths UNDER AGE 65 with an 80% infection rate would be…approximately 357,564 deaths.

This is almost as many American deaths as in World War II (405,399).
While it’s true that death rates are low for those under 35, this strategy would still lead to an estimated 4765 deaths in that age group, more than died on 9/11. (See below for the full breakdown of expected deaths by age).

• . But let’s acknowledge that even the best bubbles are leaky. With the extremely high levels of infection in the under 65s actively desired for this strategy, some infection is bound to spill over to the over 65s via those that work in hospitals and nursing homes, multigenerational living arrangements and caregiving, etc. What if only 10% of over 65s were infected, which would seem like quite successful “shielding” overall?

A 10% “spillover” infection rate in the over-65s would lead to an *additional* 396,000 deaths in the over 65s.

All told, attempting to end the COVID-19 pandemic quickly via the BEST CASE scenario of 80% infections in those under 65 and 10% in those 65 & over leads to over 753,000 expected deaths, almost the equivalent of 2 American World War IIs and almost half of those deaths in those under age 65.

The number of hospitalizations & ICU admissions would be many multiples of these death numbers.

• But that’s the *best-case* scenario if everything goes as planned. This proposition does not account for (or even mention) the unknowns of duration of immunity and possibility for re-infection. If immunity is short-lived as in other coronaviruses, a continuous supply of new people into the “susceptible” pool due to waning immunity would mean this protective herd immunity would perpetually be just out of reach. Vaccine induced immunity, on the other hand, can produce more robust and durable immunity than natural infection.

• The strategy does not acknowledge AT ALL any risks of COVID-19 to younger people beyond death. But COVID-19 affects not only the lungs, but also the heart, kidneys, blood vessels, and possibly the brain. While we don’t have good estimates of the prevalence of “Long Covid” yet, the mounting evidence of long-term health effects should give us pause before *actively seeking out* widespread infection among the young. If 80% of young people aged 0-34 are infected and *only* 2% experienced chronic Long Covid, this would be 2.4 million young people in the US with potentially debilitating symptoms requiring continued health care and hindering their ability to work and participate in society.

• The idea that large segments of society could be sealed off from the rest of society is difficult to imagine in practice, and supporters of this approach have provided no details on how this magic could be achieved. Let’s say the definition of vulnerability is age-based (though we know in reality risk is also associated with sex, pre-existing conditions, etc). Besides multi-generational households, millions of younger people work in nursing homes and hospitals and other industries where this contact cannot be avoided. Professor William Hanage likens the strategy to protecting antiques in a house fire by putting them all in one room, standing guard with a fire extinguisher but simultaneously fanning the flames. This doesn’t end well- but instead of your antiques it’s your loved ones.

• Finally, it is a straw man argument to claim our COVID options are ‘majority back to normal’ vs ‘lockdown.’ As you might have noticed, we are no longer in lockdown. While life is far from what it was prior to March, many activities have resumed, but many people are also taking voluntary precautions. Remember the stated goal of the “focused protection” strategy is to achieve a HIGH level of infections among the non-shielded group. With the virus running wild and hospitalization and deaths piling up even in the so-called “non-vulnerable” it’s unlikely that a large percentage of people will be rushing back to public spaces, meaning the strategy will fail to achieve its goal of resuming economic and social activity.

• . Proponents of the shielding approach assert that natural immunity is the only way out of this pandemic mess. They imply they would like the virus to spread quickly to achieve this…ALMOST AS IF IT WOULD BE IDEAL IF YOU COULD INJECT PEOPLE WITH THE VIRUS TO SPEED UP THE PROCESS OR SOMETHING. We may be months away from such a solution-called a vaccine- but with the benefit of hundreds of thousands of avoidable hospitalizations and deaths compared to “natural” immunity. Strangely, the proponents of the focused protection approach have not even mentioned vaccines and treatments in the pipeline and why certain disease and death for many would be preferable to continued public health measures to minimize transmission for several more months.

• Finally, we want to say that this is a complicated issue worthy of open and honest discussion, but this “debate” is often mischaracterized by a minority seeking headlines and attention. Very few public health scientists and professionals are advocating a return to lockdown, and all are concerned with the indirect effects of lost jobs and education. We should all be discussing the trade-offs inherent in specific policies going forward and do our best to prioritize essentials such as schools and non-COVID health care while supporting those individuals and industries taking the biggest economic hits. But the reality is that the countries that have returned almost to “normal” are the ones that managed to suppress the virus to low levels through aggressive testing, track and trace and a combination of other preventive measures.

The path to “natural” immunity leads to both death AND economic destruction, one way or another.

There is a better way. Continuing to #StaySMART and minimizing transmission along with a commitment to improve our test, track and trace infrastructure can go a long way to getting us to the happier version of this ending. It won’t be easy, but we can do a lot better than closing our eyes and hoping we can “skip to the end.”

Source for age-specific infection fatality rates used in calculations above   (Table 3)

US age-sex population estimates

Expected deaths by age group (80% infection rate, IFRs from source above)
55-64: 254,809
45-54: 75,188
35-44: 22,802
0-34: 4765

(10% infection rate, IFRs from source above)
65-74: 78,939
75-84: 137,192
85+: 179,938

Further reading:


The Guardian

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