The Centers for Disease Control and Prevention (CDC) examined the changing age distribution of the COVID-19 pandemic in the United States during May–August by assessing three indicators: COVID-19–like illness-related emergency department (ED) visits, positive reverse transcription–polymerase chain reaction (RT-PCR) test results for SARS-CoV-2, the virus that causes COVID-19, and confirmed COVID-19 cases, reported CDC.
Early in the pandemic, COVID-19 incidence was highest among older adults. During June–August 2020, COVID-19 incidence was highest in persons aged 20–29 years, who accounted for >20 percent of all confirmed cases. Younger adults likely contribute to community transmission of COVID-19. Across the southern United States in June 2020, increases in percentage of positive SARS-CoV-2 test results among adults aged 20–39 years preceded increases among those aged ≥60 years by 4–15 days.
Nationwide, the median age of COVID-19 cases declined from 46 years in May to 37 years in July and 38 in August. Similar patterns were seen for COVID-19–like illness-related ED visits and positive SARS-CoV-2 RT-PCR test results in all U.S. Census regions. During June–August, COVID-19 incidence was highest in persons aged 20–29 years, who accounted for >20percent of all confirmed cases. The southern United States experienced regional outbreaks of COVID-19 in June. In these regions, increases in the percentage of positive SARS-CoV-2 test results among adults aged 20–39 years preceded increases among adults aged ≥60 years by an average of 8.7 days (range = 4–15 days), suggesting that younger adults likely contributed to community transmission of COVID-19. Given the role of asymptomatic and pre-symptomatic transmission, strict adherence to community mitigation strategies and personal preventive behaviors by younger adults is needed to help reduce their risk for infection and subsequent transmission of SARS-CoV-2 to persons at higher risk for severe illness.
CDC examined age trends during May–August for 50 states and the District of Columbia (DC) using three indicators: 1) COVID-19–like illness-related ED visits; 2) positive SARS-CoV-2 RT-PCR test results; and 3) confirmed COVID-19 cases. COVID-19–like illness-related ED visits, reported by health facilities to the National Syndromic Surveillance Program (NSSP), had fever with cough, shortness of breath, or difficulty breathing in the chief complaint text or a discharge diagnostic code for COVID-19 and no diagnostic codes for influenza. Analyses of COVID-19–like illness-related ED visits were based on the ED visit date.
SARS-CoV-2 RT-PCR test results were obtained from COVID-19 electronic laboratory reporting data submitted by state health departments (37 states) and, when age was unavailable in state-submitted data, from data submitted directly by public health, commercial, and reference laboratories (13 states and DC). Data represent the number of specimens tested, not individual persons who received testing. Analyses were based on the specimen collection date or test order date. The daily percentage of positive SARS-CoV-2 test results (percent positivity) was calculated as the number of positive test results divided by the sum of positive and negative test results.
Confirmed COVID-19 cases were identified from individual-level case reports submitted by state health departments; analyses were based on the date the case was reported to CDC. Confirmed COVID-19 cases had a positive SARS-CoV-2 RT-PCR test result. Case data represent individual persons (some of whom might have had multiple positive test results). Monthly incidence was calculated using 2018 U.S. Census population estimates.
National case counts, percentage distributions, and estimated incidence of confirmed COVID-19 cases were calculated by 10-year age increments and by month (May–August). The weekly median age of persons with COVID-19–like illness-related ED visits, positive SARS-CoV-2 test results, and confirmed COVID-19 cases, as well as that of persons for whom all SARS-CoV-2 tests were conducted, were plotted nationally for the four U.S. Census regions. To minimize the impact of testing availability on findings, the early pandemic period (January–April) was excluded.
The southern United States experienced regional COVID-19 outbreaks during June–July 2020. For U.S. Department of Health and Human Services (HHS) Regions 4, 6, and 9, daily percent positivity was plotted for four age groups (0–19 years, 20–39 years, 40–59 years, and ≥60 years). The segmented package (version 1.2-0) in R software (version 3.6.0; The R Foundation) was used to segment the age group-specific trend lines and identify inflection points when the slopes changed.
National incidence of confirmed COVID-19 increased from 185 cases per 100,000 persons in May to 316 in July, then declined to 275 in August. During May–July, incidence increased among persons in all age groups <80 years, with the largest increases in persons aged <30 years. As a result, the median age of confirmed COVID-19 cases decreased from 46 years in May to 37 years in July and 38 years in August. During June–August, incidence was highest among persons aged 20–29 years, who accounted for the largest proportion of total cases (>20percent). Similar age shifts were observed nationwide.The median age trend lines for all three indicators (COVID-19–like illness-related ED visits, positive SARS-CoV-2 test results, and confirmed COVID-19 cases) followed similar patterns in the national data (Figure 1) and within each U.S. Census region; however, patterns differed by region. Nationally and in the South and Midwest, median age decreased until mid- to late June, increased during July, and decreased in the latter half of August. In the West, median age declined from May to mid-June and then remained relatively stable or slightly increased during July–August. In the Northeast, median age of persons with positive test results and confirmed cases was stable in May, decreased sharply in June, increased slightly in July, and decreased in August; median age for persons with COVID-19–like illness-related ED visits declined steadily from mid-June to mid-August. In all four U.S. Census regions, the median age of persons for whom all SARS-CoV-2 tests were conducted was relatively stable in May (whereas median age of persons with positive test results and confirmed cases declined in May) and began to decrease following declines in the other three indicators.
During June 2020 in HHS Regions 4, 6, and 9, the change to an upward slope in percent positivity among persons aged 20–39 years occurred an average of 8.7 days (range 4–15 days) before the change to an upward slope among persons aged ≥60 years. This pattern was most evident in Region 4 (Southeast) where the increase in percent positivity among persons aged 20–39 years preceded increases among persons aged 40–59 years by 9 days and those aged ≥60 years by 15 days; percent positivity among persons aged 0–19 years increased steadily from early May to early July. Within HHS Regions 6 and 9 (Southcentral and Southwest), the percent positivity among persons aged 0–19, 20–39, and 40–59 years increased at approximately the same time and preceded increases among persons aged ≥60 years by approximately 7 days in Region 6 and 4 days in Region 9.
This report provides preliminary evidence that younger adults contributed to community transmission of COVID-19 to older adults. Across the southern United States in June 2020, the increase in SARS-CoV-2 infection among younger adults preceded the increase among older adults by 4–15 days (or approximately one to three incubation periods). Similar observations have been reported by the World Health Organization. Further investigation of community transmission dynamics across age groups to identify factors that might be driving infection among younger adults and subsequent transmission to older adults is warranted.
These findings have important clinical and public health implications. First, occupational and behavioral factors might put younger adults at higher risk for exposure to SARS-CoV-2. Younger adults make up a large proportion of workers in frontline occupations (e.g., retail stores, public transit, child care, and social services) and highly exposed industries (e.g., restaurants/bars, entertainment, and personal services), where consistent implementation of prevention strategies might be difficult or not possible. In addition, younger adults might also be less likely to follow community mitigation strategies, such as social distancing and avoiding group gatherings. Second, younger adults, who are more likely to have mild or no symptoms, can unknowingly contribute to pre-symptomatic or asymptomatic transmission to others, including to persons at higher risk for severe illness. Finally, SARS-CoV-2 infection is not benign in younger adults, especially among those with underlying medical conditions, who are at risk for hospitalization, severe illness, and death.
Increased prevalence of SARS-CoV-2 infection among younger adults likely contributes to community transmission of COVID-19, including to persons at higher risk for severe illness, such as older adults. Emphasis should be placed on targeted mitigation strategies to reduce infection and transmission among younger adults, including age-appropriate prevention messages, restricting in-person gatherings and events, recommending mask use and social distancing in settings where persons socialize, implementing safe practices at on-site eating and drinking venues, and enforcing protection measures for essential and service industry workers. Given the role of asymptomatic and pre-symptomatic transmission, all persons, including young adults, should take extra precautions to avoid transmission to family and community members who are older or who have underlying medical conditions. Strict adherence to community mitigation strategies and personal preventive behaviors by younger adults is needed to help reduce their risk for infection and minimize subsequent transmission of SARS-CoV-2 to persons at higher risk for severe COVID-19.
