key: cord-0965033-xqpsdc8u
authors: Christie, Athalia; Henley, S. Jane; Mattocks, Linda; Fernando, Robyn; Lansky, Amy; Ahmad, Farida B.; Adjemian, Jennifer; Anderson, Robert N.; Binder, Alison M.; Carey, Kelly; Dee, Deborah L.; Dias, Taylor; Duck, William M.; Gaughan, Denise M.; Lyons, Brianna Casey; McNaghten, A.D.; Park, Meeyoung M.; Reses, Hannah; Rodgers, Loren; Van Santen, Katharina; Walker, David; Beach, Michael J.
title: Decreases in COVID-19 Cases, Emergency Department Visits, Hospital Admissions, and Deaths Among Older Adults Following the Introduction of COVID-19 Vaccine — United States, September 6, 2020–May 1, 2021
date: 2021-06-11
journal: MMWR Morb Mortal Wkly Rep
DOI: 10.15585/mmwr.mm7023e2
sha: 597365757239f711eddca1f443d43f013f907fd2
doc_id: 965033
cord_uid: xqpsdc8u

Throughout the COVID-19 pandemic, older U.S. adults have been at increased risk for severe COVID-19-associated illness and death (1). On December 14, 2020, the United States began a nationwide vaccination campaign after the Food and Drug Administration's Emergency Use Authorization of Pfizer-BioNTech COVID-19 vaccine. The Advisory Committee on Immunization Practices (ACIP) recommended prioritizing health care personnel and residents of long-term care facilities, followed by essential workers and persons at risk for severe illness, including adults aged ≥65 years, in the early phases of the vaccination program (2). By May 1, 2021, 82%, 63%, and 42% of persons aged ≥65, 50-64, and 18-49 years, respectively, had received ≥1 COVID-19 vaccine dose. CDC calculated the rates of COVID-19 cases, emergency department (ED) visits, hospital admissions, and deaths by age group during November 29-December 12, 2020 (prevaccine) and April 18-May 1, 2021. The rate ratios comparing the oldest age groups (≥70 years for hospital admissions; ≥65 years for other measures) with adults aged 18-49 years were 40%, 59%, 65%, and 66% lower, respectively, in the latter period. These differential declines are likely due, in part, to higher COVID-19 vaccination coverage among older adults, highlighting the potential benefits of rapidly increasing vaccination coverage.

On June 8, 2021 , this report was posted as an MMWR Early Release on the MMWR website (https://www.cdc.gov/mmwr).

Throughout the COVID-19 pandemic, older U.S. adults have been at increased risk for severe COVID-19-associated illness and death (1) . On December 14, 2020, the United States began a nationwide vaccination campaign after the Food and Drug Administration's Emergency Use Authorization of Pfizer-BioNTech COVID-19 vaccine. The Advisory Committee on Immunization Practices (ACIP) recommended prioritizing health care personnel and residents of long-term care facilities, followed by essential workers and persons at risk for severe illness, including adults aged ≥65 years, in the early phases of the vaccination program (2) . By May 1, 2021, 82%, 63%, and 42% of persons aged ≥65, 50-64, and 18-49 years, respectively, had received ≥1 COVID-19 vaccine dose. CDC calculated the rates of COVID-19 cases, emergency department (ED) visits, hospital admissions, and deaths by age group during November 29-December 12, 2020 (prevaccine) and April 18-May 1, 2021. The rate ratios comparing the oldest age groups (≥70 years for hospital admissions; ≥65 years for other measures) with adults aged 18-49 years were 40%, 59%, 65%, and 66% lower, respectively, in the latter period. These differential declines are likely due, in part, to higher COVID-19 vaccination coverage among older adults, highlighting the potential benefits of rapidly increasing vaccination coverage.

CDC analyzed the age distribution of COVID-19 vaccination during December 14, 2020-May 1, 2021. To visualize trends before and after vaccine introduction, rates of reported COVID-19 cases, ED visits, hospitalizations, and deaths by age group are presented for September 6, 2020-May 1, 2021. Daily data about COVID-19 vaccine doses administered in the United States, including partial and full vaccination, were collected by vaccination providers and reported to CDC through multiple sources.* Daily COVID-19 case data were obtained from CDC's case-based surveillance system † as reported by jurisdictional health departments. Daily ED visits for patients with a diagnosis of COVID-19 § (COVID-19 ED visit) were obtained from the National Syndromic Surveillance Program. Daily admissions data on persons newly admitted to a hospital with a laboratory-confirmed COVID-19 diagnosis at the time of admission (COVID-19 hospital admission) were obtained from the U.S. Department of Health and Human Services (HHS) Unified Hospital dataset. ¶ Weekly COVID-19 death data were collected from CDC's National Vital Statistics System.** U.S. Census Bureau midyear 2019 population estimates (as of July 1, 2020) † † were used to calculate vaccination, case, hospital admission, and death rates per 100,000 population. ED visits were shown as visits with a COVID-19 diagnosis per 100,000 ED visits reported. † To assess differences by age, CDC calculated the weekly proportion, rate, and rate ratio by age group for COVID-19 outcomes, including cases, ED visits, hospital admissions, and deaths. § § Trends were examined by plotting weekly rates by age group and rate ratios comparing persons aged ≥65 years (≥70 years for hospital admissions ¶ ¶ ) with those aged 18-49 years during September 6, 2020-May 1, 2021. Differences in age group-specific average weekly proportions, rates, and rate ratios for COVID-19 outcomes were compared during two periods: November 29-December 12, 2020 (prevaccine) and April 18-May 1, 2021 (most recent data available, accounting for reporting lag); 95% confidence intervals (CIs) and p values for these differences and for rate ratios were constructed by applying the parametric bootstrap method to 10,001 replicate pseudosamples (3). Analyses were conducted using R software (version 4.0.0; R Foundation). These activities were reviewed by CDC and were conducted consistent with applicable federal law and CDC policy.*** COVID-19 vaccine administration increased from introduction on December 14, 2020, to a peak 7-day moving average of 3.3 million doses per day in mid-April before decreasing to 2.2 million doses per day by May 1, 2021 ( Figure 1 ). Among persons aged ≥65 years, 25% had received ≥1 vaccine dose by February 6, 2021, 50% by March 3, 2021, and 82% by the end of the analysis period, May 1, 2021 ( Figure 1 ). Among persons aged 18-49 years, 7%, 10%, and 42% had received ≥1 vaccine dose by the same dates, respectively. By May 1, 2021, 69% of persons aged ≥65 years and 26% of persons 18-49 years were fully vaccinated.

COVID-19 incidence increased in all age groups during September 6, 2020-January 2, 2021, and then decreased ( Figure 2 ). The weekly rate ratio of COVID-19 incidence among older adults to younger adults was highest in late December and then declined. Compared with the prevaccination period of November 29-December 12, 2020, COVID-19 incidence during April 18-May 1, 2021, was 69% lower among all adults, and 79%, 71%, and 66% lower among persons aged ≥65, 50-64, and 18-49 years respectively (Table) . The proportion of COVID-19 cases diagnosed in persons aged ≥65 years decreased from 16.0% to 10.7% (p<0.001). The rate ratio of COVID-19 incidence among persons aged ≥65 years to that among persons aged 18-49 years decreased 40% (p<0.001) from 0.68 (95% CI = 0.67-0.68) to 0.40 (95% CI = 0.40-0.41) (p<0.001). § § Patient age was unknown for 8% of vaccinated persons, 0.7% of cases, 0.4% of ED visits, 4% of hospital admissions, and <0.01% of deaths. ¶ ¶ Hospital admissions were submitted by predefined age group (<18 years, 18-19 years, 10-year age groups from 20-79 years, and ≥80 years) and could not be aggregated from single year of age as was done for cases, ED visits, and deaths. *** 45 C. During September 6, 2020-May 1, 2021, COVID-19 ED visits per 100,000 ED visits peaked among all age groups during the week of January 3-January 9, 2021, approximately 1 week after the peak in incidence ( Figure 2 ). The weekly rate ratio of COVID-19 ED visits among older adults to younger adults was highest in mid-January and then declined. Compared with the prevaccination period of November 29-December 12, 2020, COVID-19 ED visits per 100,000 ED visits during April 18-May 1, 2021, were 59% lower among all adults, with a larger change for persons aged ≥65 years (77%) than for other age groups (Table) . During November 29-December 12, 2020, and April 18-May 1, 2021, persons aged ≥65 years accounted for 37.9% and 20.7%, respectively, of adult COVID-19 ED visits. The rate ratio of COVID-19 ED visits per 100,000 ED visits among persons aged ≥65 years to those among persons aged 18-49 years decreased 59% (p<0.001) from 1.99 (95% CI = 1.96-2.01) to 0.82 (95% CI = 0.80-0.84).

Rates of COVID-19 hospital admissions peaked during the week of January 3-January 9, 2021, approximately 1 week after case incidence peaked ( Figure 2 ). The trend in the weekly rate ratio of COVID-19 hospital admissions among older adults to younger adults followed a similar pattern as ED visits. Compared with hospital admissions during the prevaccination period of November 29-December 12, 2020, adult COVID-19 hospital admissions rates were 63% lower among all adults, with the largest change (78%) among adults aged ≥65 years, during April 18-May 1, 2021. Although COVID-19 admissions remained highest among persons aged ≥70 years, the proportion of adult COVID-19 hospital admissions among this age group decreased from 45.6% during November 29-December 12, 2020, to 27.6% during April 18-May 1, 2021 (p<0.001) (Table) . The rate ratio of COVID-19 hospital admission rates among persons aged ≥70 years to those among persons aged 18-49 years decreased 65% (p<0.001) from 9.60 (95% CI = 9.45-9.76) to 3.33 (95% CI = 3.26-3.41) (p<0.001).

During September 6, 2020-May 1, 2021, weekly COVID-19 death rates peaked between January 3-January 16, 2021, among all age groups and then decreased through May 1, 2021 ( Figure 2 ). The weekly rate ratio of COVID-19 deaths among older adults to those among younger adults was highest in mid-December and then declined. Mortality remained highest for persons aged ≥65 years; however, the proportion of COVID-19 deaths that occurred among this age group decreased from 84.2% during the prevaccination period of November 29-December 12, 2020, to 68.0% during April 18-May 1, 2021 (p<0.001) ( 

Weekly COVID-19 incidence among adults increased during September 6, 2020-January 2, 2021. After this peak, incidence, followed by rates of ED visits, hospital admissions, and deaths declined among all adult age groups. During September 6-December 14, 2020, before the commencement of vaccine administration, the rate ratios of COVID-19 outcomes among older adults to younger adults were either stable or increasing. The ratio for COVID-19 deaths began to decline in mid-December while rate ratios for COVID-19 incidence, ED visits, and hospital admissions began to decline in late December to mid-January. Comparing the 2-week prevaccination period with 2 weeks in late April, declines were significantly greater among older adults, who had higher vaccination coverage, than among younger adults, who had lower coverage. These age-stratified results provide ecologic evidence End of reporting week of the likely contribution of vaccination coverage to reducing COVID-19 outcomes.

These data are consistent with other preliminary reports showing a reduction in COVID-19 cases and severe illness in populations with high vaccination coverage. An ecologic study from Israel found the ratio of COVID-19 patients aged ≥70 years requiring mechanical ventilation to those aged <50 years declined 67% within 3 months of a nationwide vaccination campaign prioritizing persons aged >60 years (4) . In separate studies analyzing Israeli surveillance data, COVID-19 incidence, hospitalizations, and deaths markedly declined across all age groups as cumulative vaccination coverage increased (5) , and vaccine effectiveness of 46% for COVID-19 infection, 74% for hospitalization, and 72% for death, was observed during 14-20 days after the first dose (6) . A CDC evaluation at 24 hospitals found that receipt of COVID-19 vaccine was 64% effective against COVID-19 hospitalization among partially vaccinated adults aged ≥65 years and 94% effective among fully vaccinated adults aged ≥65 years (7) .

The findings in this report are subject to at least five limitations. First, this was an ecologic analysis based on aggregated data that does not account for variability in reporting or vaccination coverage among jurisdictions, between rural and urban areas, or by race and ethnicity. Second, states and territories adapted ACIP recommendations (8); therefore, the populations eligible and timing of each vaccination phase varied across jurisdictions. Third, the case, ED, and hospital data are subsets of total outcomes, and all data are subject to reporting inconsistencies and delays. Fourth, the analysis does not account for concomitant effects, including the spread of more transmissible SARS-CoV-2 variants, the general surge and subsequent decline in COVID-19 cases, the use of recommended therapeutics (9) , and the implementation and relaxation of community-level prevention policies in individual jurisdictions. However, by analyzing the relative changes in ratios comparing rates between older and younger age groups, these results were less likely to be influenced by population effects that might have affected all age groups similarly. Finally, no attempt was made to quantify the percentage of these differential rate ratio changes that were potentially attributable to vaccination. The decline in the rate ratio for deaths between older and younger adults, for example, began just after vaccine introduction; therefore, vaccine coverage can account for only part of the decline. Time trend analyses, and other analytic approaches, might enhance understanding of the impact of vaccination on population-level dynamics.

From November 29, 2020, to May 1, 2021, COVID-19 incidence, ED visits, hospital admissions, and deaths declined more in older adults, who had higher vaccination coverage, than in younger adults, who had lower coverage. Despite sufficient vaccine supply and expanding eligibility, administration of COVID-19 vaccines has steadily declined in adults since mid-April 2021. These results suggest that tailored efforts by state and local jurisdictions to rapidly increase vaccine coverage among all eligible age groups could contribute to further reductions in COVID-19 cases and severe outcomes. Such efforts include effectively communicating the benefits of vaccination, ensuring equitable access and convenience, empowering trusted messengers, including primary health care providers, and engaging communities. Territorial Epidemiologists on August 5, 2020 (https://ndc.services.cdc.gov/case-definitions/coronavirus-disease-2019-2020-08-05). However, some variation in how jurisdictions implement these case classifications was observed. More information on how CDC collects COVID-19 case surveillance data can be found at https://www.cdc.gov/coronavirus/2019-ncov/covid-data/faq-surveillance.html. § ED visits for COVID-19 are defined as ED visits with any of the following: ICD-10 codes U07.1 or J12.82 or Systematized Nomenclature of Medicine codes 840539006, 840544004, or 840533007. ¶ Deaths with confirmed or presumed COVID-19 as an underlying or contributing cause of death with ICD-10 code U07.1. Provisional data are incomplete. Data from May 2021 are less complete because of reporting lags. ** CIs and p values were constructed using the parametric bootstrap method using 10,001 replicate pseudosamples. CIs were formed using the quantiles of the bootstrap distributions, and p values were based on the proportion of pseudosample values below the 0.025 or above the 0.975 quantile. † † The change in measure from November 29-December 12, 2020, to April 18-May 1, 2021, was statistically significantly different (p<0.001).

What is already known about this topic? COVID-19 vaccination began in the United States in December 2020, and adults aged ≥65 years were prioritized in early phases.

What is added by this report?

By May 1, 2021, 82%, 63%, and 42% of adults aged ≥65, 50-64, and 18-49 years, respectively, had received ≥1 vaccine dose. From November 29-December 12, 2020 to April 18-May 1, 2021, the rate ratios of COVID-19 incidence, emergency department visits, hospital admissions, and deaths among adults aged ≥65 years (≥70 years for hospitalizations) to adults aged 18-49 years declined 40%, 59%, 65%, and 66%, respectively.

What are the implications for public health practice?

The greater decline in COVID-19 morbidity and mortality in older adults, the age group with the highest vaccination rates, demonstrates the potential impact of increasing populationlevel vaccination coverage.

Corresponding author: Athalia Christie, akc9@cdc.gov. 1 CDC COVID-19 Response Team.

CDC COVID-19 Response Team. Severe outcomes among patients with coronavirus disease 2019 (COVID-19)-United States

The Advisory Committee on Immunization Practices' updated interim recommendation for allocation of COVID-19 vaccine-United States

Bootstrap methods for standard errors, confidence intervals, and other measures of statistical accuracy

Reduction in COVID-19 patients requiring mechanical ventilation following implementation of a national COVID-19 vaccination program-Israel

Impact and effectiveness of mRNA BNT162b2 vaccine against SARS-CoV-2 infections and COVID-19 cases, hospitalisations, and deaths following a nationwide vaccination campaign in Israel: an observational study using national surveillance data

BNT162b2 mRNA Covid-19 vaccine in a nationwide mass vaccination setting

IVY Network; HAIVEN Investigators. Effectiveness of Pfizer-BioNTech and Moderna vaccines against COVID-19 among hospitalized adults aged ≥65 Years-United States

COVID-19 US state policy database

COVID-19) treatment guidelines. Bethesda, MD: National Institutes of Health

Chad Heilig, Center for Surveillance, Epidemiology, and Laboratory Services, CDC.All authors have completed and submitted the International Committee of Medical Journal Editors form for disclosure of potential conflicts of interest. No potential conflicts of interest were disclosed.