Why are these elderly people who should be protected the most delayed in getting the new crown vaccine?

The vaccination conundrum for the elderly is not only a scientific problem, it is more of a social problem.

According to vaccination data released by the National Health Commission, nearly 42 million people over the age of 60 in China have not been vaccinated, and more than 100 million elderly people have not received the third dose of the new crown vaccine.

What is more troublesome is that the one-dose, two-dose and three-dose COVID-19 vaccination rates in China's elderly groups of all ages decrease with age, taking the first dose as an example, the vaccination rates of 60-69-year-olds, 70-79-year-olds and 80-89-year-olds in mainland China are 88.8%, 86.1% and 58.8%, respectively.

In the face of Omikeron, the elderly with underlying diseases are the main vulnerable population, and vaccination is their most important firewall. Due to low vaccination rates for the elderly, Hong Kong, in the fifth wave of the epidemic, has produced the highest mortality rate in the world, with an overall case fatality rate of 0.74%. According to Hong Kong epidemic data, 85.5% of hospitalizations and 95.8% of deaths in Hong Kong come from the elderly over the age of 60, while about 90% of the deceased have not completed the full vaccination, and the unvaccinated elderly over 80 years old have the highest mortality rate.

From April 17 to April 23, Shanghai added 87 new local deaths, most of which were over 85 years old, the maximum age was 101 years old, and the direct causes of death were caused by underlying diseases, and only a few people were vaccinated - the new crown vaccination rate of people aged 60 and over was only 62%; the vaccination rate of people over 80 years old was as low as 15%.

This creates a scissor difference: the more elderly people who need to be protected, the lower the vaccination rate.

It has been more than a year since the National Health Commission requested the inclusion of the elderly over the age of 60 in the immunization programme in March 2021.

But among the most vulnerable elderly groups, vaccination rates have never been among the top. Taking the third injection of the elderly over 80 years old as an example, the vaccination rate of Chinese mainland is about 20%, while the vaccination rate of Norway, Sweden and other countries exceeds 90%.

Why are vaccination rates for the elderly lower than among other populations after one year of full promotion? Why are elderly people in China reluctant to get the COVID-19 vaccine? What are the possible ways to increase vaccination rates quickly?

Eight Points interviewed a number of people in charge of vaccination and the families of the unvaccinated elderly, and in the conversation with them, they gained some enlightenment.

"Sweeping tail"

Why don't they want to get the COVID-19 vaccine?

When the vaccine coverage rate for the elderly over 60 years old in the country exceeded 85%, Chen Wenmin, head of the preventive health care section of the Xingang Street Community Health Service Center in Haizhu District, Guangzhou, was still suffering from a headache for about a quarter of the elderly who had not received the first vaccine in a street in Guangzhou, and they were almost an "iron plate crowd" who could not enter the oil and salt.

According to data released by the National Health Commission at the end of March, the vaccination rate of the elderly over the age of 60 in Jiangxi, Anhui and Shandong provinces has exceeded 90%. Chongqing, Henan, Hubei, Guizhou, Hebei, Sichuan, Yunnan 7 provinces and cities more than 85%, while the welfare of the frequent benefits of the north, Guangzhou, and the aging degree of The Heijiliao is not on the list.

Grassroots workers in Tiannanhaibei have roughly the same bitterness about all the unimmunized elderly who are extremely difficult to convince, and persuading the elderly to change their willingness to vaccinate is a "popular science", "seduction", "even scare and coaxing", "sometimes have to flicker" work.

The north, Shanghai, Guangzhou, and Shenzhen are known for their "welfare". Eight points of health news learned that many communities in Beijing have opened a two-level incentive model of "introducer + elderly vaccinator", and a community in Yizhuang has even offered a high price of "1,000 yuan cash for introducers and 2,000 yuan gift certificates for the elderly who are vaccinated for the first dose".

A community doctor told Eight Point Kenwen that they encouraged a family over the age of 60 to receive covid-19 vaccines and send 500-600 yuan gift certificates/cash, even so, "more than a dozen elderly people come to vaccinate every day."

A community worker who was vaccinated to send Universal Studios tickets told Eight Point Jianwen, "The vaccination rate of the elderly in our community is not up to standard, and the studio tickets can indeed attract some people, but the number of people attracted is limited, and we can't afford the highest rewards." But there was no way, but to continue to think of a way, and then fight."

The accessibility of vaccines is not an issue. According to the assumption, unified pick-up, mobile door-to-door service, and grass-roots seedling delivery to the door can easily improve the vaccination rate.

But what is more difficult than sending seedlings to the door is how to persuade the elderly. Chen Wenmin's sub-district, nearly half of the elderly are retired intellectuals of colleges and universities, "most of them have inherent knowledge about vaccines, think they have some insider information, although he is not necessarily a health professional, but he thinks he is well-informed and knows more than us", in the face of Chen Wenmin's "popular science", the other party is often indifferent, they will say "I know it is not what you said, you don't want to say it again."

Because the overall risk of infection in the past year is not high, the elderly group who "do not go out of the door and do not step out" cannot perceive the threat of the new crown, thus gaining a "false sense of security", "not going far away, not traveling, buying vegetables and then going home" is a common rejection term used by the elderly.

Whatever the considerations, the likelihood that older people will be denied vaccinations is higher than other populations. The underlying disease they suffer from is the weakness of the fight against COVID-19, but it is a good excuse to refuse the vaccine, and the older they are, the higher the success rate of refusing to vaccinate, because advanced age is itself a risk.

"The elderly generally have heart disease, diabetes and other underlying diseases or have undergone various surgeries large and small, and are also worried about the adverse reactions of vaccines." We have also done ideological work, shopping coupons have been prepared, people just don't fight, in line with the principle of voluntary vaccination, we can't force it, we can only call over and over again," a community worker in Beijing's Chaoyang District told Eight Point Jianwen.

"Other groups of people have a close network of social organizations, your company, school, and the social activities you participate in can all have requirements for vaccination, which actually produces a certain mandatory force," the popular science author Leng Zhe analyzed, "but for the elderly, it is difficult to have a similar mandatory." ”

The vaccination rate of the elderly in each street is determined by the age structure, willingness to vaccinate, community mobilization ability, and available vaccination resources of the elderly in the community, Chen Wenmin for example, "the same vaccination measures and mobilization efforts, the streets where the elderly over 90 years old account for the majority of the total number of people are definitely more difficult to complete than the 60-70 year old people."

This has formed a two-way causal chain of "old age - many underlying diseases, severe illness after infection, high risk of death - worry about the risk of vaccination, refusal to vaccinate - high rejection of success rate - low vaccination rate - severe illness or death after infection".

A more effective stimulus variable is the home outbreak. Almost all respondents agreed that when an outbreak occurs, vaccination targets for this week or this month will be well done.

However, the implementation of epidemic prevention and vaccination work is the same group of people, and in the reality of the epidemic in more than 20 provinces, the focus of many of the grass-roots workers interviewed has shifted from vaccination to nucleic acid testing, and some regions have even suspended vaccination.

Vague contraindications

Underlying diseases should be the reason for strengthening vaccination, but in reality, it has become the biggest obstacle for the elderly to get vaccinated.

Even if the elderly have a strong willingness to vaccinate, they must also pass the contraindication screening to get the new crown vaccine, but the eight-point healthy news found that the screening standards for contraindications in various places and even at various vaccination points are not completely consistent, and the population of common chronic diseases in the elderly is very large, and some vague contraindications will directly affect the vaccination rate.

Take high blood pressure, for example. According to the 2015 epidemiological survey, the prevalence of hypertension in people over 60 years old in China is 53.2%, while in the elderly people over 80 years old, the prevalence of hypertension is close to 90%, which means that one in every two people over 60 years old has high blood pressure, and almost everyone over 80 years old has high blood pressure.

The management of chronic diseases in the elderly in China has always been a big problem, the overall control rate of hypertension in the elderly over 60 years old is only 18.2%, and only a few people can take medicines on time to control blood pressure according to medical advice. Zhang Mo, a nurse at a township health center in Chifeng City, Inner Mongolia, found in her work that more than 40% of the elderly vaccinated people had high blood pressure in the routine physical examination before vaccination.

Strictly speaking, high blood pressure is not one of the five categories of contraindications. The first and only edition of the Technical Guidelines for COVID-19 Vaccination issued in the mainland stipulates that only the "acute onset of chronic diseases" is related.

However, when localities index the "acute onset of chronic diseases", a line has been pulled out, that is, "blood pressure below 160/100 mmllg can only be vaccinated". If the elderly in China want to be vaccinated against the new crown, almost everyone needs to cross this blood pressure threshold.

According to this high-pressure line, a doctor at a vaccination site in Beijing told Eight Point Jianwen that whether it is psychogenic "white coat hypertension", or blood pressure instability "in the onset period", or long-term hypertension, as long as the blood pressure is found to be higher than 160/100mmHg after the on-site physical examination, it will be suspended.

In order to vaccinate the mother with high pressure for many years to receive the new crown vaccine, Leng Zhe consulted many parties to find a vaccination site that was willing to "risk", and the explanation given by the doctor was that although the cold mother had high blood pressure and blood sugar, she was in a stable state, and high blood pressure was not contraindicated, and low instability was contraindicated.

But in reality, the blood pressure of the elderly in China is mostly unstable, "many elderly people forget to take medicine, poor management, blood pressure will come up", if the vaccinator has enough time, community workers will even let the elderly take medicine on the spot to reduce blood pressure "over the line" and then vaccinate.

Nurse Zhang Mo told Eight Point Health That they generally do not vaccinate patients with hypertension above 160/100mmHg "because they may have other underlying diseases that have not been detected", "but if the vaccinator is willing, they will also be vaccinated after signing the informed consent form".

But Chen Wenmin in Guangdong said that hypertension is not in the five categories, and there is no direct relationship with the new crown vaccination, "if the vaccinator has high blood pressure, but the patient himself does not have any physical discomfort, we will also recommend him to vaccinate."

"Strictly speaking, there is only one category of contraindicated people, that is, those who are severely allergic to the vaccine components", vaccine science expert Tao Lina suggested that the guidelines be "more active" through evaluation techniques.

"Even if it is a cancer patient, as long as he does not take immunosuppressants and his life expectancy exceeds 1 year, we will recommend that he be vaccinated," Zhang Yujiao, a tenured professor at MD Anderson Cancer Center in the United States, told Eight Point Health News, and people with low immune function should be more worried about not being able to produce enough immune response.

One immunologist commented, "The current experience of vaccination in the elderly with various underlying diseases is relatively limited and requires targeted research and guidance. To solve the problem of vaccination for the elderly, it is necessary to make certain investments, summarize the past vaccination experience and laws, and try to make vaccination safer and more effective."

Bad fears

Ineffectual coupling reactions

Lymphoma was diagnosed four months after his mother received the second dose "uncomfortable for a month" and his father received the second dose, and although no correlation identification was made, Mr. Long of Yunnan Province mobilized everyone in the family to no longer be vaccinated against the new crown.

Although many older adults are at risk of developing disease at any time, at a coincidental point in time, people always put it all down to vaccines.

Coupling response refers to a person who is in the incubation period or early stage of the onset of the disease, but happens to be vaccinated during this period, and the recipient becomes ill after vaccination, but the onset of the disease is not related to the vaccine.

The probability of this coincidence happening to the elderly is particularly high, because vaccination targets 260 million elderly people, and this population itself is characterized by the high incidence of diseases such as cerebral infarction, stroke, and cancer, so no matter what time point the vaccination falls, a large number of elderly people will develop diseases around this time point.

But "the priority relationship does not represent causation, I think the vast majority of the so-called abnormal reactions are coupled, not caused by vaccines", Tao Lina believes that the key is to eliminate coupling events through monitoring and analysis, correct adverse events caused by vaccines, and give the grassroots a reassuring pill.

"After our assessment, the vaccination is uncomfortable can come to us, if you come, we will follow the work specifications, guide the medical treatment, track the report, if you need identification, we will also help him submit information together to apply for identification", Chen Wenmin is not shy about the coupling reaction and the occurrence of adverse events, "If the identification results say that it is not related to the vaccine, then the vaccine is not back, and there will be no compensation." If it is related to vaccines, the most serious consequences will be compensated accordingly in accordance with the procedure. As long as the vaccination specifications are met, there will be no trouble for the grass-roots institutions. ”

However, the current coupling identification results are often faced with the embarrassment of "show meets soldiers" when facing the general population. A staff member of the Immunization Planning Office told Eight Point Jianwen, "We also made an appraisal of the recently reported cases, and the result was coupling disease, which has nothing to do with vaccination, but the family does not spare, what can we do?" ”

The spread of so-called "adverse reactions" by a small number of "coupled reactions" through various channels will also lead to the expansion of the refusal population. Many grassroots workers have been exposed to some cases of children blocking the vaccination of the elderly at home, "they have heard about the so-called adverse events from nowhere", and some people will even ask the staff to write a letter of commitment, declaring that they are responsible for the discomfort that may occur after the elderly are vaccinated.

However, a number of vaccination doctors have reported that in more than a year of vaccination practice, the more the vaccine is played, the more reassuring it is, "at the beginning of the preparation of an ambulance, and then after the mass vaccination, no one came to find it and withdrew."

Between the coupled responses affecting the population and the vaccine with a higher actual safety profile is the Tacitus trust problem. There are regional differences in the monitoring of abnormal reactions after vaccination, and some rural areas with extremely high vaccination rates do not have "coupling" or "serious adverse events", while some urban areas with high awareness of rights protection, although the vaccination rate is not prominent, frequently find "abnormal reactions". Among all the "abnormal reactions", there are those who do not report, such as Mr. Long, who believe that even the reported results will be coupled, so the "self-considered unlucky" has become anti-vaccine, and some reporters have been stuck in the "autopsy" link in the identification of adverse reactions.

Tao Lina believes that the key to solving this problem is to give a firmer and more reasonable scientific explanation through official monitoring and big data analysis, "whether it is coupling or adverse reactions, common coupling reactions, what are adverse reactions, what is the incidence, can not be ambiguous, let the vaccine back the black pot."

The above-mentioned immunologists suggested that "vaccine manufacturers should be encouraged to conduct relevant research, and experts should also analyze the large-scale population that has been vaccinated, given that the elderly population is more likely to have coupled reactions, so it cannot be ignored, otherwise it is easy to cause safety problems."

Who bears the risk?

In the cases learned by Eight Points of Health, the vaccination model explored by various places is that the community mobilizes for mobilization, the grass-roots health institutions carry out contraindication screening and vaccination, and the contraindications that the vaccinators cannot judge must have a public hospital to issue a contraindication certificate.

The forward operation of this process divides people who are willing to be vaccinated into vaccinated groups and contraindicated groups. But for the elderly and other vulnerable groups, each link in the process has to consider how to take on risks.

A staff member of the Central Regional Immunization Programme Admitted that for elderly vaccinators with underlying diseases who are worried about "adverse reactions", whether they are given contraindication certificates or vaccinated, they must bear risks.

If there is no good risk sharing mechanism, in order to avoid risks, grass-roots vaccination institutions will "get tighter and tighter" in the judgment of taboos, and even "advanced age" itself has become a taboo.

Although there are several centenarians in the village, Xiao Wan's highest only mobilized a 93-year-old man to be vaccinated, "and I really didn't dare to fight anymore, nor did I mobilize them."

A grassroots worker once left a message on the eight-point health news, "The elderly have many basic diseases, many people have cancer and stroke, they all think that it is caused by receiving vaccines, they will ask the vaccination institutions for free treatment and compensation, and the superior will refuse to vaccinate the elderly and people with underlying diseases."

"Some elderly people or family members say that there is cancer, we dare not say too much," a street worker in Foshan told Eight Point Jianwen, "Last month we took an elderly person to get vaccinated, when the doctor noticed that the elderly were a little depressed, and the blood sugar was high during the physical examination, it was recommended not to vaccinate or delay vaccination." But within a few days, the old man accidentally fell and died. We were a little bit thankful at the review, and if we had been vaccinated, it might have become another incident."

In the face of more complex immunocompromised people, professionally, doctors in grass-roots vaccination units should make more complex judgments that integrate basic diseases and individual immune functions.

Leng Zhe introduced the vaccination experience of a CKD (chronic kidney disease) patient in Jiangsu and Zhejiang regions to Eight Points Jianwen, "When the patient went for the first time, he declared that he had CKD when signing the consent form, and the result was that the vaccination site refused to vaccinate him, and the second time the patient took the medical record written by the nephrologist "The patient is ready to be vaccinated against the new crown vaccine in the near future, unwell follow-up" and asked for vaccination, but the vaccination site still refused to vaccinate him, and the third time she changed the vaccination site and did not mention the CKD thing to the doctor. As a result, the vaccine was normal, and now the whole process has been completed."

"The willingness of the elderly to vaccinate is not high, the vaccination institutions avoid risks, if this crux is not solved, it will become a dead knot that hinders the Chinese elderly group from vaccinating against the new crown vaccine", Zhang Yujiao told Eight Points Jianwen, "The principle of vaccine side effects is that the body has a fierce immune response to the vaccine, but the elderly with underlying diseases generally have weak immune function, and the immune response caused by the vaccine is not as intense as that of young people, in theory, its side effects on the elderly are lower than those of young people."

Zhang Zijie, a researcher at the State Key Laboratory of Conservation and Utilization of Biological Resources conservation and utilization at Yunnan University, introduced a retrospective study of 1266 subjects in an online lecture on April 11, and the data showed that the adverse reactions of subjects over 60 years old were lower than those in the subgroup aged 40-59 years in both the health group and the underlying disease group.

Zhang Yujiao called for changing the erroneous understanding of the high incidence of adverse events in the vaccination of immunodeficient people, and accurately assessing the feasibility of vaccination of the elderly with underlying diseases, stable cancer patients, diabetes, cardiovascular diseases and respiratory diseases and children as soon as possible, and vaccinate them against the new crown.

How to speed up the process of immunization of the elderly?

Most countries in the world with the highest vaccination rates for the elderly have adopted some more flexible vaccination models according to the actual situation.

Starting from the willingness to vaccinate, the vaccination strategies of the elderly population in various countries can be divided into three modes: mandatory, semi-mandatory and voluntary, corresponding to Italy, Singapore and Japan.

In the wave of infections in Europe at the beginning of this year, there are still about 1.5 million people over the age of 50 who have not been vaccinated in Italy, and after the daily increase in infections exceeds 90,000 and the hospitalization rate soars by 20% a week, in order to alleviate the pressure on the medical system, Italy has linked vaccinations with personal work, fines, and accounts to "implement mandatory vaccination obligations for people over 50 years old."

In order to promote vaccination, Singapore stipulates that those who fail to receive covid-19 treatment will lose their eligibility for free COVID-19 treatment, and those who have not received COVID-19 vaccination cannot dine in and enter shopping malls and attractions. At the end of last year, when the epidemic situation was grim, Germany also adopted similar restrictions on the entry of unvaccinated people into non-essential living places.

In Japan, the elderly are the second priority group after medical care. Professor Kentaro Iwata, an infectious disease expert at Kobe University in Japan, said in an interview with The Paper that some countries may not be too worried about the new crown because of the long-term absence of the epidemic, and feel that there is no need to take risks to get vaccinated. Japan has experienced six waves of outbreaks so far, and the willingness of the elderly to be vaccinated is high.

In terms of improving access to vaccines, mobile vaccination, door-to-door delivery of seedlings, and extension of service hours at vaccination sites are common practices in various countries.

"I oppose large-scale one-on-one door vaccination, which is not in line with vaccination norms and is not conducive to emergency disposal," Chen Wenmin told Eight Point Jianwen, compared with community mobilization and bulk vaccination, the elderly groups with institutional belongings, such as retirement units and nursing homes, will be more smoothly vaccinated. However, the dilemma of centralized vaccination in the community under medical care is insufficient manpower.

Another big problem for China is time. According to the general requirements, the vaccination of the enhanced needle should be carried out after 6 months after the full vaccination, and Zhang Yujiao suggested that for the elderly group, the evaluation should be considered to shorten the vaccination interval. On 4 March, Hong Kong announced a reduction in the time between COVID-19 vaccinations and reduced the interval between the third dose and the second dose from six months to three months.

To increase or maintain immunity intensity, more than a dozen countries, including Israel, Australia, Italy, Japan, the United Kingdom, Sweden, France, Germany, and the United States, have approved or are discussing fourth vaccination for the elderly population.

A spokesman for Singapore's Ministry of Health said that "people who live in aged care facilities such as nursing homes often have comorbidities and should receive a fourth dose even if they are not yet 80 years old".

"The current COVID-19 vaccine lacks upgrades and improvements that keep pace with the times," the immunologist suggests, "research and development should be strengthened while advancing vaccination," and "pilot populations can be selected to scientifically assess the incidence of coupling responses and adverse events, as well as to assess the immune effect after vaccination." If the antibodies produced after vaccination and their maintenance time are not enough, then other ways may need to be found to make up for it."

(Xiao Wei is a pseudonym)

Yu Huanhuan and Yan Shengnan | writing

Chen Xin | responsible editor

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