Safety of Older People During the Covid-19 Pandemic: Co-Residence of People Aged 65+ in Poland Compared to Other European Countries

Bearing in mind that the estimated fatality rates related to Covid-19 infections are substantially higher among older people, in this Policy Paper we focus on the demographic composition of households of people aged 65+ as one of the social risk factors that influence the consequences of the pandemic. In light of plans of easing isolation restrictions and a gradual return to higher economic activity, a key challenge for the coming weeks is to ensure the safety of those most at risk. Although lifting the lockdown mainly affects the lives of the working population and children, attention should be paid to the channels that could enhance transmission of the coronavirus among older people. This includes the prevalence of co-residence with those who will get back to their workplaces or schools once they are open again. Compared to other European countries, Poland has the highest rates of people aged 65+ sharing their households with younger adults and children with nearly 40% living together with people aged up to 50 years old (excluding partners). On the other hand, Nordic countries, the Netherlands, Belgium and Germany report far lower rates of co-residence among the older population. In these countries however, older people commonly reside in formal care facilities, which, in turn, have proved vulnerable to outbreaks of infections. This emphasizes that each country has to carefully determine its own strategy on the way to recovery. Among other factors, the pace at which restrictions on social distancing are lifted should take into account the prevalence of co-residence among the older population.

Introduction

According to the WHO, at the early stage of the Covid-19 epidemic, the fatality rate among coronavirus-infected people was estimated at about 3-4% (WHO 2020a), although estimates based on the data from European countries suggest that the rate is lower and is closer to 1.5% (ECDC 2020). The rate is quite varied from country to country; it also fluctuates over time. To a large extent, the figure depends on the number of tests conducted and, consequently, the reliability of information on the number of people infected (Roser et al. 2020). Nevertheless, both the risk of experiencing serious symptoms of the coronavirus infection and the risk of death from complications arising from the disease increase significantly with the age of the infected person. Furthermore, the risk is definitely higher for the patients with underlying conditions, in particular cardiovascular diseases, diabetes, or hypertension (Emami et al. 2020). The highest risk is observed among older persons, with the fatality rate of people infected fluctuating from 1.8%-3.5% in the 60-69 cohort, to 13.0%-20.2% in the 80+ cohort (Roser et al. 2020). Therefore, a major challenge in the area of health and socio-economic policy measures in the coming months is to keep the older population safe and contain the spread of coronavirus in that population.

This Policy Paper presents an analysis of the housing situation of people aged 65+ in Europe. Co-residence may be one of the relevant social risk factors that determine the probability of being infected with viruses which, like SARS-Cov-2, are spread through droplet transmission. As shown by research on intra-household transmission at the early stages of the epidemic in China, the majority (75%-85%) of clusters (group illnesses) were observed within households (WHO 2020b). Depending on the data, the coronavirus secondary attack rate within households is estimated at 7.6%-15.0% (Bi et al. 2020; KCDC 2020b), and from this perspective it is important to note that the incidence rate is the highest in the 20-29 age group, with most of them showing no symptoms of the disease while being able to infect others (KCDC 2020a).

Given the limited scope of labor market activity in the 65+ population, compliance with the self-isolation regime by this group will not interfere much with the gradual easing of socio-economic restrictions. Things look different among younger people due to their work or study, and among the youngest members of the population due to their school or pre-school attendance. In line with the regulations introducing the state of epidemic in Poland, since March 23rd, 2020, many workplaces have been operating on a remote basis, with their labor force doing work from home, and many companies and organizations having been closed. Similarly, the nurseries, kindergartens, schools and universities have been closed since the 16th of March this year. However, the government has already announced a plan to ease some of the restrictions to pave the way for a phased return to more intensive social contacts and economic activity (Council of Ministers 2020). Because of the shortcomings of distance learning and serious inequalities in access to education in this system (Myck et al. 2020), and considering the adverse impact of closed schools and kindergartens on the working parents, it seems imperative to resume the operation of these facilities as soon as possible.

A key challenge for the coming weeks will therefore be to reconcile the socio-economic benefits of lifting the lockdown with the risk of health implications arising from less stringent social distancing restrictions. Those implications may be particularly severe for older people. Thus, this Policy Paper discusses structural determinants of the well-being of older people, with a focus on the housing situation in European societies and the rate of co-residence with the younger population. The analyses outline the status in Poland in comparison to other European countries, pointing to a great diversity of health risks for older people. One factor is the difference in the prevalence of co-residence between the older and younger populace, and another is the prevalence of formalized care facilities. Next to disease statistics, these differences should be taken into account in any decisions on lockdown easing or a detailed design of policy measures.

In Poland, the percentage of people aged 65+ in co-residence with other members of the household aged 50 or below (excluding a spouse or partner) is 37.4% for the female population and 38.6% for the male population, i.e. the highest in Europe. In Poland, 12.0% of people aged 65+ share a household with school-age children (aged 7-18), and 7.7% live together with children aged 0-6. Co-residence with minors usually means, for obvious reasons, that the adult parents of the minors live under the same roof as well. However, Poland also reports one of the highest percentages of co-residence with other adults without minors. For example, 7.6% of people aged 65+ live in one household with people aged 19-30, and 17.3% share a household with adults aged 31-50 who are not their spouses or partners. It is worth noting, however, that in the European countries considered here a high percentage of co-residence is negatively correlated with the prevalence of collective dwelling facilities that deliver formalized care for older persons. In Poland, the supply of such institutions – whether public or private – has been very limited, with only 1.6% of people aged 80+ living in those facilities. In contrast, in Belgium, almost every fourth person of that age is a resident of such a facility. When it comes to the pandemic, it must be underscored that although in such institutions the interactions with younger people can be quite easily limited, the experience of many countries has shown that they have been quite vulnerable to coronavirus clusters and epidemic outbreaks.

Considering that Poland reports the highest percentage of co-residence among people aged 65+, particular attention should be paid to the challenges for health and socio-economic policy measures introduced in Poland to manage the intensity of social contacts during the pandemic. This, in particular, applies to the regulations on students returning to schools and the easing of social distancing rules for students and working adults. Therefore, in countries such as Poland, the restoration of frequent social contacts, which is necessary, inter alia, to put the economy back on track, will have to be accompanied with adequate safeguards for those who are most heavily exposed to negative health effects of Covid-19.

The first section of this Policy Paper reviews co-residence percentage data for the 65+ population, based on data for Europe (the European Union member states and Norway, Switzerland and the United Kingdom, for the remaining European countries the data is not available), from the 2017 European Union Statistics on Income and Living Conditions study (EU-SILC.) The second section presents data on older people living in long-term care facilities in a number of European countries, collected in recent years by the OECD.

1. Older People in Co-Residence With Other Members of the Household

In the analytical discussions below, the terms “co-residence” or “shared household” refer to a situation where persons aged 65+ live in one household with adults who are not their spouse or a partner, or with children under 19 years of age. In Poland, the percentage of households shared by people aged 65+ and children aged 18 or younger is one of the highest in Europe. Of all the older people in Poland that live in a household setting on a permanent basis (i.e. excluding those living in formalized care facilities), as many as 16.9% of women and 16.6% of men aged 65+ share a household with persons under 19 years of age (cf. Figure 1). With the exception of Slovakia and Romania, other countries report a much lower rate. In countries such as Norway, Sweden, Denmark, or the Netherlands, the rate is between 0.1% and 0.6% for women, and between 0.5% and 1.2% for men (65+ population).

Figure 1. Population aged 65+ in co-residence with persons other than their spouse/partner, by the age of the youngest member of the household

a) Male

b) Female

Source: Authors’ compilation based on the 2017 EU-SILC data.
Nota Bene: Share of 65+ population not living in formalized care facilities.

In Poland, approximately 12% of women and men aged 65+ share a household with students aged 7-18. In other words, more than 460k women and 280k men aged 65+ in Poland have direct, daily interactions with students attending schools (Table 1). In addition, 13.9% of women and 14.7% of men aged 65+ (530k and 360k, respectively) share a household with persons aged 19-30, who – according to research findings from other countries – demonstrate the highest incidence of coronavirus disease (KCDC 2020a). On top of that, these proportions are significantly higher in rural areas, and over 40% of the 65+ population in Poland live in rural areas. Compared to other countries in Europe, it is especially in the rural areas that Poland reports a significantly higher percentage of older people in co-residence with younger people (Figure 2). For example, while in Poland 19.0% share a household with children aged 7-18, and 21.1% with people aged 19-30, in Sweden in the 65+ population in rural areas those percentages are 0.4% and 1.0%, respectively, and in Belgium 1.9% and 1.5%. In urban areas the disparities in the demographic structure of households between Poland and other European countries are less pronounced, but still the share of the 65+ population in co-residence with younger people is among the highest in Europe; with 7.2% sharing a household with school children and 9.5% with adults aged 19-30. In Sweden these percentages are 0.7% and 1.7%, respectively, and in Belgium 1.2% and 3.8%.

Table 1: Population aged 65+ in Poland in co-residence with other members of the household (other than a partner/spouse).

Source: Authors’ compilation based on the 2017 EU-SILC data.

Nota Bene: Share of 65+ population not living in formalized care facilities.

Figure 2. Population aged 65+ in co-residence with other members of the household (other than a partner/spouse), by age of the other members of the household.

1. Urban

Rural

Source: Authors’ compilation based on the 2017 EU-SILC data. Nota Bene: Countries: SE – Sweden, BE – Belgium, IT – Italy, HU – Hungary, ES – Spain, SK – Slovakia, PL – Poland. Share of 65+ population not living in formalized care facilities.

2. Residents of Formalized Care Facilities for Older Persons

Households where people aged 65+ live under one roof  with younger people (usually they are all family members) reflect the financial status of the family on the one hand, but on the other they offer care to those who might need it to due to their age or health status. In that respect, unlike many other countries in Europe, Poland has a very low share of older people who, due to barriers to independent living, decide to relocate to a formalized care facility or a similar setting. In 2017, less than 1% of the 65+ population in Poland lived in formalized care facilities; and for the 80+ population the share was only slightly higher and reached 1.6% (Figure 3). One reason is the low number of vacancies in such facilities: in 2017 in Poland there were, statistically, 12 beds per 1000 inhabitants aged 65+. For comparison, in Nordic countries (Denmark, Finland, Norway, Sweden) more than 12% of the 80+ population live in formalized care facilities for older people; in Luxemburg and Switzerland the rate is close to 16%, and in Belgium it is 24%. These countries also report a much higher availability: from 50 beds per 1000 people aged 65+ in Denmark to over 80 beds in Luxembourg. The share of older people living in formalized care facilities is also relatively high in countries such as Slovenia (12.6% for the 80+ population) or Estonia (9.9%).

Figure 3. Long-term care facilities – resources and utilization.

Source: Authors’ compilation based on the OECD data.
Nota Bene: According to the latest 2017 data available, with the exception of: Spain, Portugal – 2018 data; the Netherlands, Slovenia – 2016 data; Belgium, Denmark – 2014 data. The figure includes the European countries for which the data has been available. For Italy, only the data on the number of beds has been available, and for Portugal, only the data on the number of facility residents.

The isolation regime introduced to restrict the frequency of visits, side by side with a system of appropriate checks and controls for the staff, are relatively simple ways to reduce the risk of external coronavirus infection in formalized care facilities. Yet, as we have learnt from numerous examples in Poland and internationally, infection transmission between the residents or between the residents and the staff has been a frequent source of infection clusters and outbreaks. For example, in South Korea, even more than 30% of new coronavirus cases could be the result of transmission between hospital patients or nursing home residents (KCDC 2020a). In connection with a coronavirus outbreak in a formalized care facility in the USA, more than half of the residents had to be hospitalized and, eventually, 33.4% died (McMichael 2020). It seems that keeping the residents of formalized care facilities safe from the infection should be a priority in an epidemic control policy. However, the pace at which social distancing restrictions are lifted so that students can get back to schools and the lockdown in public spaces can be removed, should not have a vital impact on the safety of those living in the facilities, in contrast to the situation of older persons who share a household with younger persons.

Summary

The well-being of the groups with the biggest exposure to the grave outcomes of coronavirus infection deserves special attention when lifting the lockdown introduced in connection with COVID-19 pandemic. In this context, the housing situation of older people and the nature of the underlying social contacts are among important aspects to take into account in developing detailed regulations. As outlined in this Policy Paper, different countries in Europe report different status in that respect. Of all the countries in Europe, Poland has the highest share of the 65+ population co-residing with younger people. On the other hand, less than 1% of the 65+ population live in formalized care facilities. In Europe, the lowest share of co-residence is reported in the Nordic countries, the Netherlands, Germany and Belgium. At the same time, the share of the 65+ population residing in formalized care facilities in those countries fluctuates from 4% to 8%, reaching over 10% in the 80+ population.

In formalized care facilities, lockdown lifting will not have material impact on the safety of the residents or the risk of coronavirus transmission. In contrast, the households where older people live side by side with the younger populace may actually represent a significant risk factor in terms of the spread of the epidemic and infection transmission to those who are most heavily exposed to the grave complications of Covid-19.

In general in Poland, 37.4% of women and 38.6% of men aged 65+ share a household with people under 50 other than their spouse or partner. This is the highest rate of co-residence with younger people for this age cohort in Europe. In Denmark, this percentage is 1.3% for women and 3.3% for men. Even in Spain it is much less common for people aged 65+ to share a household with younger family members (the rates being 28.0% for women and 26.6% for men, respectively). Additionally, in Poland, especially in rural areas, many people aged 65+ live under one roof with school-age children (7-18 years of age: 19.1% of women and 18.9% of men in this age group, respectively); and even more (20.9% of women and 21.5% of men) share a household with adults aged 19-30, which is the age group where coronavirus infection is the most prevalent (KCDC 2020a).

In view of major discrepancies in the demographic structure of households between countries, it seems necessary to differentiate the social distancing rules and the pace with which these rules are to be eased, if one of the objectives is to protect the people exposed to the most serious consequences of coronavirus infection. Especially in such countries as Poland, the policy of gradual opening of schools and other institutions and phased recovery of economic activity should be accompanied by a broad-based communication campaign on how to protect the most vulnerable household members. It seems advisable that the campaign be conducted both in the mass media and in schools, workplaces, and public spaces.

References

• Bi, Q., Y., Wu, S., Mei, Ch,., Ye, X., Zou, Z., Zhang, X., Liu, L.,Wei, S., Truelove, T., Zhang, W., Gao, C., Cheng, X., Tang, X., Wu, Y., Wu, B., Sun, S., Huang, Y., Sun, J., Zhang, T., Ma, J., Lessler, T., Feng (2020). “Epidemiology and Transmission of COVID-19 in Shenzhen China: Analysis of 391 cases and 1,286 of their close contacts.” medRxiv 2020.03.03.20028423
• ECDC – European Centre for Disease Prevention and Control (2020). “Coronavirus disease 2019 (COVID-19) in the EU/EEA and the UK – eighth update.”
• Emami, A., Javanmardi, F., Pirbonyeh, N., Akbari, A. (2020).”Prevalence of Underlying Diseases in Hospitalized Patients with COVID-19: a Systematic Review and Meta-Analysis.” Arch Acad Emerg Med. 8(1): e35.
• KCDC – Korea Centers for Disease Control & Prevention (2020a). “The updates on COVID-19 in Korea.”
• KCDC (2020b). “Coronavirus Disease-19: Summary of 2,370 Contact Investigations of the First 30 Cases in the Republic of Korea.” Osong Public Health Res Perspect. 2020 Apr; 11(2): 81–84.
• McMichael T., Currie D., Clark S., Pogosjans S., Kay M., Schwartz N., Lewis J., Baer A., Kawakami V., Lukoff M., Ferro J., Brostrom-Smith C., Rea T., Sayre M., Riedo F., Russell D., Hiatt B., Montgomery P., Rao A., Chow E., Tobolowsky F., Hughes M., Bardossy A., Oakley L., Jacobs J., Stone N., Reddy S., Jernigan J., Honein M., Clark T., Duchin J. (2020). “Epidemiology of Covid-19 in a Long-Term Care Facility in King County”, Washington. N Engl J Med. 2020 Mar 27.
• Myck, M., Oczkowska, M, Trzciński, K. (2020). “School lockdown: distance learning environment during the COVID-19 outbreak.” CenEA Commentary Paper.
• Oke, J., Heneghan, C. (2020). “Global Covid-19 Case Fatality Rates“.
• Rada Ministrów (2020). “Rozporządzenie Rady Ministrów z dnia 10 kwietnia 2020 r. w sprawie ustanowienia określonych ograniczeń, nakazów i zakazów w związku z wystąpieniem stanu epidemii” [Regulation of the Council of Ministers of 10 April 2020 on establishing certain restrictions, orders and prohibitions in connection with the introduction of the state of the epidemic].
• Roser, M., Ritchie, H., Ortiz-Ospina, E. (2020). “Coronavirus Disease (COVID-19) – Statistics and Research“.
• WHO (2020a). “Coronavirus disease 2019 (COVID-19)“. Situation Report – 46.
• WHO (2020b). “Report of the WHO-China Joint Mission on Coronavirus Disease 2019 (COVID-19)“.

Disclaimer

This Policy Paper was originally published as a CenEA Commentary Paper of 21st April 2020 on www.cenea.org.pl. The analyses outlined in this Policy Paper make part of the microsimulation research program pursued by CenEA. The analyses are based on EU-SILC 2017 data as part of microsimulation research using the EUROMOD model and have been provided by EUROSTAT, and on publicly available OECD data. EUROSTAT, the European Commission, the National Statistical Institutes in each country, or the OECD have no liability for the results presented in the Policy Paper or its conclusions.

This Policy Paper was prepared under the FROGEE project, with financial support from the Swedish International Development Cooperation Agency (Sida). FROGEE papers contribute to the discussion of inequalities in the Central and Eastern Europe.  For more information, please visit www.freepolicybriefs.com. The views presented in the Policy Paper reflect the opinions of the Authors and do not necessarily overlap with the position of the FREE Network or Sida.