After months of lockdown, public congregation increased exponentially last week, as residents of major cities from coast to coast took to the streets in huge numbers to protest decades of black death at the hands of police officers, and specifically the killing of 46-year-old George Floyd in Minneapolis.
But even before the unrest and the possibility of attendant contagion, warm weather across the country prompted people to sun in public parks, take day trips to beaches, and drink in groups as states eased COVID-19 lockdowns. Relaxed restrictions have also sent thousands of young people sidelined from service industry jobs back to work in states from Texas to Vermont.
As public health experts have warned for months, any return to pre-pandemic behavior—whether at bars in Waco or demonstrations in cities like Los Angeles—could come at significant cost. In fact, if an analysis from the first COVID-19 hot spot in the United States is any indication, young people have, for weeks, appeared to be setting the stage not for a second wave of an infection, but a deadly extension of the first one.
Essentially, public health experts told The Daily Beast, the young hold the power to determine whether states can continue on a steady march toward reopening—or else veer back toward an infection spike that could force new lockdowns.
In Washington state, half of new daily infections in early May were occurring in people under 40, a dramatic increase from eight weeks earlier, when older age groups made up more than two-thirds of the patients who tested positive, according to a new report. Based on public data from the Washington Department of Health, the analysis noted that cases in Washington state peaked on March 22, then declined for a few weeks, and then sustained a plateau with an average of approximately 200 cases per day since.
“Watch what’s happening before and after the peak,” said lead author Dr. Judith Malmgren, an epidemiologist and affiliate assistant professor at the University of Washington’s school of public health. “The disease didn’t change, but the people who were infected changed.”
Malmgren said the analysis—published on the preprint site for health sciences research, medRxiv, and not yet peer-reviewed—found 39 percent of confirmed cases in the state were in the 20-39 age bracket, and another 11 percent were in those 19 or younger. Though otherwise healthy young people are less likely to suffer serious illness from the virus than those over the age of 65 or with comorbidities, the disease can cause lifelong health effects on all patients, and recent reports of a life-threatening inflammatory syndrome in children has raised significant concerns across the country.
Malmgren’s analysis was first-reported by The Seattle Times, and though it was preliminary, Washington State Health Officer Dr. Kathy Lofy told the paper it was evidence that older residents have done a promising job of social distancing. Dr. Jeff Duchin, the health officer for Public Health Seattle & King County, also posited that the pattern “reflects people’s behavior.”
Crucially, Malmgren added, young people are also more likely to work in essential jobs. That, combined with a greater desire for social interaction, may be the cause of the new bump in infections among younger Washingtonians. But, as always, it’s also a reason for concern about those in vulnerable populations who must interact with them in supermarkets, pharmacies, and elsewhere.
“In eight weeks, our demographic slipped from majority over age 60 to majority under age 40,” Malmgren told The Daily Beast. “As the epidemic got under control and people over 60 followed pretty strict social distancing and guidelines, the infection rate went down in that portion of the population. But we didn’t have the same messaging—had no messaging, basically—to young people that there’s a danger to you.”
While trend lines in New York, New Jersey, and other parts of the country had been promising in recent weeks, experts told The Daily Beast that the new analysis pointed to a disturbing trend that—with an assist from mass protests—could be replicated elsewhere.
Dr. William Haseltine, president of the global health think tank ACCESS Health International, said the reopenings and decreased case counts in some areas may have provided a “false sense of security” to young people who believe themselves invulnerable to serious infection.
“Human beings can control this epidemic without a vaccine and without a drug,” said Haseltine, pointing to the testing, contact tracing, and social distancing guidelines that created dramatic drops in case counts in countries as vastly different as Australia, China, and Denmark.
“About 20 percent of people get really ill—and some fraction, which is yet to be determined, suffer lifelong damage they will never recover from, like having their kidneys removed and put on lifelong dialysis or contracting a heart disease or a serious stroke that can cause lifelong impairment.”
But Haseltine and Malmgren both said the desire to socialize is neither surprising nor beyond understanding.
“Young people have an enormous innate drive to congregate, and to not recognize that is to not recognize our humanness,” said Haseltine. “This virus takes advantage of that.”
While the concept of herd immunity—that if enough of the population becomes infected and then immune from the virus, life can return to normal—has been discussed at length, there are significant problems with attempting to use it as a public health policy. And even in the first American hot spot, Washington’s King County, fewer than 2 percent of residents have been infected, according to estimates cited by the Times.
“There is no community in the United States which has the majority of people infected,” said Haseltine. “None.”
Or, as Malmgren put it, it would be “very dangerous” to assume that the worst of the pandemic was over just because there were more hospital beds and testing available in May than in March or April. What’s worse, she added: “If this is the number of confirmed cases in that age group, it could actually be much higher.”
“It might feel like” the risks have gone down since the pandemic first hit the U.S., but any socialization at all is “dangerous,” she added.
Dr. Irwin Redlener, director of the National Center for Disaster Preparedness at Columbia University and an expert on U.S. readiness for pandemics, called it a “delusion of normalcy” to see gradual reopenings as an indication that any community—from New York to Washington—is out of the woods. But to be fair, said Redlener, “risky behavior in younger people is always a public health issue.”
That gamble is made worse by the recent reports that have shown, for children under 18, the potentially fatal multisystem inflammatory syndrome related to COVID-19. The illness is seemingly rare, but children and teens have been tested far less than adults for the coronavirus, meaning nobody knows how many children have been infected, and “we don’t have a denominator to define that it’s a rare event,” said Malmgren. Scientists don’t have enough data to know if only one in 1,000 children with the coronavirus develops the disease or if the incidence is much, much higher, she said.
And there are still many unknowns about the way the virus behaves—including whether Malmgren’s analysis points to more young people exposing themselves to social contact or something more concerning.
“It’s almost like it’s a different disease now, at least in Washington,” said Malmgren, cautioning that the analysis likely means the disease didn’t change, but that people’s behavior changed.
But whatever the reason for the demographic shift—an unknown “change in the virus” or evidence that young people took reopenings as a signal that “things are better now”—said Redlener, these findings are “worthy of significant attention.” All the more so given that Washington state was the first hot spot with a confirmed case of community transmission and home to the first COVID-19 death in the country.
“If what’s happening in Washington becomes true nationally, we have a problem,” said Redlener. “Every state and the federal government need to be following this very, very closely.”
And all three experts agreed that any conversation about a possible second wave of infections misses a crucial point: We’re not out of the first wave anywhere in the U.S., and we still do not have enough testing or contact-tracing to adequately handle subsequent outbreaks.
“My message to the rest of the country,” said Malmgren, is that “your strategy is going to have to change” as demographics shift among those who are infected.
And ultimately, she added: “You can’t manage what you don’t measure.”