"Vaccination should be accelerated in the elderly group with poor health and underlying diseases."
Written by | Ling Jun
Source | "Medical Community" public account
Since the development of the epidemic, the health risks after the new crown infection have been further concentrated in the elderly.
In Hong Kong, more than 95% of the deaths in the fifth wave of the epidemic are in the group over 60 years old, with a median age of 87 years. In South Korea, the cumulative number of infected deaths in the past two years has exceeded 22,000, accounting for 94% of the people over the age of 60. Singapore's relevant figures for the past year also exceeded 90%.
Vaccination is the most effective means of protecting the elderly. About 90% of the dead in Hong Kong's current outbreak are unvaccinated, and the number of unvaccinated deaths in Singapore is about 18 times higher than that of the completed intensive vaccination.
Under such circumstances, the vaccination rate of the elderly on the mainland is still relatively low. As of March 24, 2022, nearly 45 million people over the age of 60 on the mainland have not completed the full vaccination, and nearly 130 million people have not been vaccinated.
On April 21, 2022, Zhang Wenhong, director of the Department of Infectious Diseases at Huashan Hospital affiliated to Fudan University, publicly stated at the Boao Forum for Asia that there may be many indicators for getting rid of the epidemic in the future, but the case fatality rate of the elderly and vulnerable people with underlying diseases will always be a very important indicator.
"Only by increasing their vaccination rates and providing adequate medical resources for those infected can we really ensure that the case fatality rate is kept at a very low level." Zhang Wenhong said.
The elderly are hesitant to get vaccinated
Why is the vaccination rate of the elderly in China "not raised"?
On April 18, the School of Public Health of the University of Hong Kong published online "Why The Elderly in Hong Kong, China Postpone or Refuse Vaccination", conducting in-depth interviews with 27 unvaccinated elderly people on the issue of "vaccine hesitation".
According to the paper, some elderly people have expressed concerns about the safety of vaccines, and low "health literacy" and limited access to comprehensive medical information have made them more concerned and concerned about the news of vaccine side effects with the title of "appalling".
At the same time, most of the participants downplayed the risk of the outbreak and showed hesitation about the effectiveness and necessity of the vaccine, and the interview was conducted between 16 December 2021 and 23 January 2022, when the number of daily covid-19 infections in Hong Kong was only about a few dozen, and there were almost no deaths.
"I see news all over the world and the probability of infection is high. But Hong Kong is completely different, so I am not worried in Hong Kong. ”
"I'm not too worried about COVID-19 because I do a good job of personal hygiene and avoid going to crowded places."
"I don't think the COVID-19 pandemic is serious, I didn't wear a mask during SARS, but nothing happened..." the three participants said.
This was followed by the outbreak of the fifth wave in Hong Kong, with more than 8,700 people over the age of 60 dying. The case fatality rate for those aged 70-79 who were fully vaccinated was 0.36%, while the case fatality rate for unvaccinated was as high as 5.6%.
The situation of "vaccine hesitation" is similar in mainland areas. As of April 28, the full COVID-19 vaccination rate of the elderly over the age of 60 in Shanghai was only 62%, and the intensified vaccination rate was 38%.
Before the outbreak of this round of the epidemic, Shanghai has been a nationwide "excellent student in epidemic prevention", and a family member of an unvaccinated elderly person told the "medical community" that the elderly live in nursing homes, and most of the people living with them are not vaccinated.
In his words, it's too safe. The domestic epidemic itself is not serious, and nursing homes have repeatedly emphasized that it is a closed management, and once there is an infection in the society, even family visits will be canceled. Coupled with the inconvenience of the elderly going out, vaccination has not been taken seriously.
Since then, Shanghai has suffered a "broken defense", the family member revealed that dozens of elderly people on the same floor have been infected one after another. According to the information released by the Shanghai Municipal Health Commission, as of April 25, the cumulative number of infected deaths in Shanghai in this round of the epidemic was 190, 95% of which were over 60 years old, and only 12 cases had been vaccinated against the new crown.
A similar situation is available in Beijing. According to the Life Times, the heads of several elderly care institutions in Beijing said, "Many times of mobilization, some elderly people are still reluctant to get vaccinated." Pi Beibei, secretary of the Party Committee of the Fresh Community in Chaoyang Street, Dongcheng District, Beijing, said that about 60% or 70% of the elderly aged 60 and above in the community were vaccinated against the new crown, but less than 30% of the elderly over 80 years old were vaccinated.
"In order to encourage the elderly to be vaccinated against COVID-19, some communities have issued incentives, such as rice, eggs, shopping vouchers, etc., and more people can indeed be vaccinated." Several community workers told Life Times, but this was a helpless move because there were still elderly people on the sidelines.
Elderly people with "underlying diseases" who can't get vaccinated
The problem isn't just for the elderly. Some elderly people "don't even get vaccinated", while others can't get vaccinated if they want to.
Ms. Chen in Shanghai told the "medical community" that her father had a history of coronary heart disease and had implanted two stents. The doctor at the vaccination site told her father that one stent could be vaccinated and two could not be vaccinated. Ms. Chen expressed incomprehension of such a distinction, not to mention that according to the "Technical Guidelines for COVID-19 Vaccination (First Edition)" issued by the National Health Commission, coronary heart disease and "stents" are not included in the contraindications to vaccination.
Mr. Ling, a 62-year-old who lives in Xiamen, felt the same way, telling the "medical community" that community doctors had made it clear that if the blood pressure exceeded 160/100mmHg, the vaccine could not be vaccinated.
"Contraindications to Vaccination" in the "Technical Guidelines for COVID-19 Vaccination (First Edition)", Source: The Paper
Zhang Zhenhua, director of the Department of Infectious Diseases of the Second Affiliated Hospital of Anhui Medical University, believes that a large part of the reason is that in the current official COVID-19 vaccination guidelines and vaccination recommendations issued by various places, the scope of contraindications is too vague or too harsh, resulting in low reference value and operability in practice.
In the past year, Director Zhang Zhenhua's infection team has participated in the vaccination safety and security work more than 100 times. At least in the jurisdictions the team was responsible for, Zhang Zhenhua observed that many community doctors "stayed away" from the elderly with underlying medical conditions.
"Not to mention that high blood pressure itself does not affect COVID-19 vaccination, which can at least be measured on the spot." Zhang Zhenhua said, "What about high blood sugar? What about chronic liver disease? What about hyperthyroidism? ”
According to the "guidelines", contraindications to COVID-19 vaccination include acute onset of chronic diseases, or patients with uncontrolled serious chronic diseases, "but the community doctors have limited examination methods, and some diseases require specialist judgment on whether they are stable, resulting in certain difficulties for community doctors to accurately judge the real-time health of the elderly." ”
Cautious community doctors may send these elderly people to a specialist or tertiary hospital for examination and issue a certificate of "vaccination" or contraindications. But for most of the elderly, the willingness to vaccinate is not high, so much trouble, the examination also needs to spend money, many people simply give up vaccination. ”
Zhang Zhenhua believes that the "contraindications" in the guidelines or recommendations should avoid the existence of "ambiguous" situations as much as possible, and unless there are extremely individual cases, community doctors should not be allowed to bear too much responsibility for individualized medical judgments.
"Strictly speaking, only patients with malignant tumors in the radiotherapy and chemotherapy phase, patients in the active phase of AIDS, patients with uncontrolled infectious diseases, rheumatic diseases or those who are being treated with high-dose hormones and immunosuppressants, and pregnant women can be postponed." Zhang Zhenhua said, "The absolute contraindications to vaccination are mainly people who are allergic to the vaccine ingredients or have a history of severe allergies." ”
But looking at the world, Zhang Zhenhua's suggestions can still only be regarded as "conservative". In the Uk Health Safety Agency's February 28 update of the "Green Paper on COVID-19 Vaccines", high-risk groups in the elderly, that is, those with serious underlying diseases, are considered to be clinically "extremely vulnerable", but instead prioritize in the vaccination program. Another vaccination recommendation states that patients with blood tumors, AIDS patients with poor viral load control, patients with weakened immunity due to radiotherapy/chemotherapy or other biological therapy... A third booster should be given as soon as possible.
UK "COVID-19 Vaccine Green Book", web translation
The Green Paper notes that these risk groups are at high risk of complications from COVID-19, and multiple agencies, including WHO, believe that the benefits of vaccination outweigh the risk of any rare side effects that may occur. Vaccinations can be given unless otherwise contraindicated.
According to the VACCINE guidance of the US Centers for Disease Control and Prevention, people with moderate or severe immunocompromised function need to receive 3 doses of mRNA vaccine to complete the primary vaccination.
"Inactivated vaccines are already relatively mild, and I suggest that older people should also be given more potent vaccines." Virology expert Chang Rongshan believes that it is particularly important to establish a correct "vaccine cognition", and vaccination should be accelerated in the elderly group with poor health and underlying diseases, because they have obtained higher benefits than the opposite.
How to determine adverse reactions after vaccination
The global vaccination situation over the past year or so has amply demonstrated the safety of various mainstream COVID-19 vaccines.
But it is unavoidable that when the number of vaccinated people rises to the order of "100 million", it is only a matter of probability that some adverse reactions of different severity will occur after vaccination.
The situation becomes more complex when further concentrated in the elderly population. The elderly are a high incidence of all kinds of "small hairy diseases" every day, when those uncomfortable symptoms that will appear happen to occur after vaccination, even if it is not related to vaccination, the "back pot" is often a vaccine.
In Zhang Zhenhua's description, the local response mechanism to a similar situation is roughly as follows:
If discomfort symptoms occur after vaccination, they will be evaluated in a medical institution first, and if it is determined that it is not related to the vaccine, it will be treated according to the normal disease treatment process;
If it is determined that the relevant or not excluded related, the patient can find the community doctor responsible for vaccination with the report issued by the corresponding medical institution, and the community will be responsible for reporting and going through the compensation/reimbursement process.
However, this seemingly reasonable process has many problems in practice.
"Determining symptoms of discomfort and vaccine-related is a relatively complex diagnostic process that requires highly senior doctors and even expert groups to discuss intensively, and is time-consuming and laborious. And once the diagnosis of 'uncorrelated', not all patients or family members are willing to accept, there are always people who do not rely on it, insisting that the health problems that arise are related to vaccination. ”
"Therefore, many medical institutions often issue 'do not exclude related' certificates, neither uncertain nor negative, and send patients back to the community." Zhang Zhenhua said, "And for community doctors, this means not only getting the 'benefits' of vaccination, communicating, writing reports... There's also a bunch of hassles. "Such a situation also occurs more frequently in first- and second-tier cities where citizens have a higher awareness of rights protection."
"More is better than less." Zhang Zhenhua said that as a result, the enthusiasm of community doctors to vaccinate the elderly has been further reduced, "The key to solving the problem is to establish an authoritative official institution to implement a unified adverse reaction identification process." ”
"With more than 3.3 billion doses of vaccination experience on the mainland, it's time to study and develop a 'identification template' for related adverse reactions. When the vaccinated person has symptoms of discomfort, the medical institution only needs to carry out relevant health examinations according to the requirements of the template, and report the results, and the responsibility for final judgment and explanation is borne by the 'authoritative body'. ”
"If the official judgment is an adverse reaction after vaccination, the compensation for compensation." If it is determined that it is not related, then it is useless for the patient to find anyone. Zhang Zhenhua said that community doctors only need to concentrate on completing the task of "receiving everything that should be received".
Zhang Zhenhua believes that the side effects of the elderly with underlying diseases after vaccination may be higher than those of the general population, but whether to be vaccinated should comprehensively judge the risks and benefits of patient vaccination, and the existence of small probability side effects cannot ignore the huge health risks that may be caused by not vaccinating in the future.
Vaccinations should be prioritized
On March 7, 2022, Kaiser Health News ("Caesar Health Network") published an article reviewing the epidemic prevention situation in the United States in the past two years since the outbreak of the epidemic, and believes that based on the original economic and medical strength of the United States, the results are not ideal.
But if there is one point in particular worth mentioning, the vaccination rates of the elderly must be one of them. In the United States, where the full vaccination rate is only about 66%, the vaccination rate for the elderly aged 65 to 75 reaches 92.4%.
Vaccination rates for people of different ages in the United States
Elderly deaths in the United States were particularly prevalent in the early stages of the pandemic. But starting in February 2021, vaccination rates for people over the age of 65 in the U.S. began to climb, and the total weekly death toll of people over the age of 75 in the United States fell sharply depending on the number of deaths by date.
Although there have been two recoveries since then under the influence of mutant strains, related policy fluctuations and other factors, it has not returned to the previous "peak" level.
Based on ample evidence of the effectiveness of COVID-19 vaccines in protecting the elderly, countries are advancing vaccination of the elderly.
The full vaccination rate in Singapore is about 95% for people over the age of 60. According to the new regulations issued by the Singapore government at the end of last year, from 2022, only 2 doses of mRNA vaccine or 3 doses of inactivated vaccine will be considered "complete vaccination", and those who do not complete it will be restricted from entering public places such as shopping malls, restaurants and libraries.
South Korea also briefly introduced a "vaccine pass" last December, and public places such as movie theaters and restaurants are only open to those who have completed vaccinations.
Domestic strategies are more based on "science education" and "incentive measures", and according to previous media reports, in the past year, when there was a more serious outbreak of local epidemics in various places, there was often a wave of vaccination peaks.
Lu Mengji, a German-American virologist and professor at the Institute of Virology at the University of Essen School of Medicine, expressed concern, telling the "medical community" that in the face of Opmi Kerong, in the long run, even strict epidemic prevention measures cannot avoid foolproof, and "breaking the defense" may only be a matter of probability of "when, where and who".
"The vaccination rate of the elderly in China is too low, and once the large-scale spread of the new crown epidemic occurs, the existing medical resources are not enough to cope with the hospitalization rate and severe illness rate during the peak period abroad." Lu Mengji said, "At present, China is still in the protection period of 'dynamic clearance', and only by seizing this opportunity can we eliminate the threat of the new crown virus in the future at the least cost by further vaccination of more effective vaccines and increasing the vaccination rate of the elderly." ”
Chang Rongshan told the "medical community" that with reference to the early practices of foreign countries, medical resources should be more rationally allocated, research and development, updating or introducing more effective vaccines should be accelerated, and vaccination priorities should be set, so that young people can be vaccinated later, the pressure on medical workers can be reduced, and the energy should be more focused on the priority vaccination of "the elderly and immunodeficient populations".
It is reported that at present, in Shanghai, where the local epidemic is the most serious, Zhao Dandan, deputy director of the Municipal Health Commission, introduced at the press conference on the prevention and control of the epidemic on April 28 that at present, under the premise of controllable epidemic risk, the elderly are focusing on actively promoting new crown vaccination. For example, arrange mobile vaccination vehicles into the community, set up temporary vaccination points in pension institutions, etc., specially transport the elderly in the community, set up vaccination windows for the elderly, etc., to provide more convenient and warm vaccination services.
Wu Liangyou, deputy director of the Disease Control Bureau of the National Health Commission, said in Beijing on the same day that the overall progress of new coronavirus vaccination is smooth, the work of strengthening immunization is being carried out in an orderly manner, and the vaccination rate for the elderly over 60 years old is also significantly improved.
Resources:
[1] Why do Chinese older adults in Hong Kong delay or refuse COVID-19 vaccination? A qualitative study based on Grounded Theory，https://assets.researchsquare.com/files/rs-1569282/v2/c21f7930-e14b-46a5-a49e-d1d2f35862a2.pdf?c=1651075414
Source: Medical community
Editor-in-charge: Ling Jun
Proofreader: Zang Hengjia