Differential COVID-19 infection rates in children, adults, and elderly: Systematic review and meta-analysis of 38 pre-vaccination national seroprevalence studies

Background Debate exists about whether extra protection of elderly and other vulnerable individuals is feasible in COVID-19. We aimed to assess the relative infection rates in the elderly vs the non-elderly and, secondarily, in children vs adults.Methods We performed a systematic review and meta-analysis of seroprevalence studies conducted in the pre-vaccination era. We identified representative nation-al studies without high risk of bias through SeroTracker and PubMed searches (last updated May 17, 2022). We noted seroprevalence estimates for children, non-elderly adults, and elderly adults, using cut-offs of 20 and 60 years (or as close to these ages, if they were unavailable) and compared them between dif-ferent age groups.Results We included 38 national seroprevalence studies from 36 different coun-tries comprising 826 963 participants. Twenty-six of these studies also includ-ed pediatric populations and twenty-five were from high-income countries. The median ratio of seroprevalence in elderly vs non-elderly adults (or non-elderly in general, if pediatric and adult population data were not offered separately) was 0.90-0.95 in different analyses, with large variability across studies. In five studies (all in high-income countries), we observed significant protection of the elderly with a ratio of <0.40, with a median of 0.83 in high-income countries and 1.02 elsewhere. The median ratio of seroprevalence in children vs adults was 0.89 and only one study showed a significant ratio of <0.40. The main limitation of our study is the inaccuracies and biases in seroprevalence studies.Conclusions Precision shielding of elderly community-dwelling populations be-fore the availability of vaccines was indicated in some high-income countries, but most countries failed to achieve any substantial focused protection.Registration Open Science Framework (available at: https://osf.io/xvupr)