Until recently, the majority of coronavirus cases that Dr Quinn Snyder, an emergency doctor at one of Arizona’s largest emergency departments, saw were older people. But since mid-May, when the state’s stay-at-home order was lifted, and particularly after the Memorial Day holiday, the demographic has shifted.
Snyder says he has seen an “explosion” in cases among 20-44 year-olds.
Some of those, he said, are coming in severely ill – requiring oxygen, intubation and ventilators. “We even had people in that age group die, unfortunately. So it’s very troubling and it’s very difficult to watch young people die from this disease. It’s horrible.”
As cases continue to soar at record levels across the US, which now has over 2.6m cases, there is growing alarm about a surge in younger people getting the virus. On Friday, vice-president Mike Pence said half of new cases in the US in recent weeks were adults under 35.
Speaking ahead of the July 4 holiday weekend, health experts in hotspot states – which include Arizona, Texas and Florida – warned numbers will continue to rise and that if young people do not take better precautions, hospitals will reach capacity and states could be left with no choice but to completely shut down.
Factors thought to have contributed to the surge in cases amongst younger people include graduation parties, mixed public messaging, higher risk tolerance and bars.
Around half of Arizona’s almost 80,000 cases fall into the 20-44-year-old age bracket. Nightclubs and bars – closed this week as part of Republican governor Doug Ducey’s “pause” of reopening in an attempt to stop the spread – are the “primary reservoir” for the disease, said Snyder.
He wants to see a stay-at-home order and urged young people to stay at home.
“The truth is that if we are going to contain this pandemic, if we are going to prevent our hospitals from overflowing, it’s absolutely critical that people in the 20-44-year-old age group take much more precautions than they currently are taking and stay at home.”
Some state and federal officials – including Donald Trump - have put the rise in US cases down to increased testing. But Dr Katherine Ellingson, an infectious disease epidemiologist at the University of Arizona, said this is definitely not the case in Arizona, where she said “the rise in Covid testing has not kept pace with the rise in cases”.
She said: “The trends are highly concerning … it’s very likely that we will see conditions worsen before they get better.”
Between late March and late June, Ellingson said the mean age of new cases in the state dropped from 51 to 38. She puts the change down to a combination of factors including businesses reopening, the end of the stay-at-home order and a general “quarantine fatigue”.
She said young people should take precautions including mask wearing, avoiding large gatherings, maintaining physical distance and hand hygiene. She added: “When we look at accounts of super-spreading events we see some common themes: people indoors and in close proximity, doing things like eating, drinking, singing, or exercising.”
The state has, however, issued a moratorium on consumption of alcohol at bars.
Mary Jo Trepka, professor and chair of the department of epidemiology at Florida International University, said the median age of recent cases in the state has been in the 30s. On June 23 it was 33, currently it’s 37.
“That means that half of the people are 37 or younger who are testing positive for covid-19,” she said. “That’s really pretty remarkable, how large that number is, especially since you would still think that more frail people would be more likely to be identified because they’re going to have more severe illness.”
On Tuesday there were 152,434 total cases in Florida – a rise of 6,012 on the previous day – and 3,505 deaths. Trepka said the true number of cases is likely to be even higher because data undercounts younger people who are more likely to be asymptomatic or only have mild symptoms.
“The message early on, probably so people didn’t completely panic, was that ‘OK, this is a lot like the flu, the very elderly are most at risk, but the young people are much less risk’. And while that’s still true of course, once you start getting a lot of young people that are infected, some of those people will be hospitalized and some may die.”
The increase in infections among young people poses a significant risk to older people – especially in multi-generational households, which she says is “very worrisome”.
While new measures such as the restriction on bars, fines for not wearing masks in Miami Beach and beach closures in some counties may help, Trepka said it will take at least two weeks before their impact is felt. In the meantime, she predicts, cases will continue to go up.
“Are we going to have a complete shutdown? I hope not, but it all depends on what happens in the hospitals.”
I really hope that seeing upticks in the young population being hospitalised is a wake-up call
Dr Spencer Fox
Experts say that bars have become a hotbed for transmission – particularly as people drink and lose their inhibitions.
Dr Amesh Adalja, an infectious disease doctor and a senior scholar at Johns Hopkins Centre for Health Security, said bars are “coming up in multiple case investigations”.
“Because of the very nature of being at a bar is a social function, it’s much less likely that you’re going to see social distancing be observed there and people, as they drink alcohol, they may talk louder, they may yell, cheer, sing and scream.
“It does pose a higher risk for transmission. And most bars are indoors as well.”
After stay-at-home orders were lifted, he said many people wrongly took it as a “green light that things were safe”.
There was, he added, “a lot of pent-up desire to interact and to go to bars and do things that they couldn’t do for the last couple of months and that’s what you’re seeing – basically like everybody turning 21 all of a sudden”.
Bar closures could have some impact, but he fears it could lead to people being “driven underground” to house parties and believes spread among younger age groups will continue which could then start chains of transmission among older and vulnerable people.
On Tuesday, Texas reported 6,900 new cases and 6,533 people in hospital – b0th daily records for the state, which has a total of nearly 160,000 total cases. Just over a month after they were allowed to reopen, bars were last week ordered to close and restaurants reduced to 50% indoor capacity.
Dr Spencer Fox, associate director of the UT Austin Covid-19 Modelling Consortium, said: “What we’re seeing in Texas are rises in cases in young people … We’ve seen large upticks in the absolute number of hospital patients who are in younger demographics.”
Their current working hypothesis is that younger people, who are lower risk, were more likely to resume socialising when the state started reopening.
If action isn’t taken by authorities and younger people continue this behaviour, he said the spread they will “continue to see exponential growth – in cases, infections, hospitalisations and mortality”.
Fox also fears it will lead to surges among older age groups too.
“I really do hope that seeing upticks in the young population being hospitalised is a wake-up call to people in those age groups, that even though they are maybe less likely to have a negative consequence, it’s still happening, and it’s happening at a rate that is pretty alarming.”