How can China's elderly be better protected from COVID waves?

A "vaccination culture" is emerging among the most vulnerable

After China optimized its epidemic prevention and control measures, the country is experiencing a massive wave of COVID-19 infections. Compared with the preceding strains of COVID-19, Omicron is less pathogenic but more contagious. Given its extremely fast transmission speed, coupled with China's huge population, the number of people at risk is staggering even though the rate of severe cases and mortality are very low at present. How to protect vulnerable groups in China thus has become an urgent issue.

Your Ginger River's grandmother on his father's side and grandfather on his mother's side are both over 90 years old and have underlying health issues. His grandmother had actively taken three doses of the vaccine prior to the outbreak. His grandfather took the first dose earlier this year and experienced pain in his arm for several days afterward, so he did not take the second. However, because of the outbreak, he is now considering taking the second one.

Some readers of this newsletter have asked Ginger River why China's elderly vaccination rate is not high enough. The above-mentioned example showed that the situation varies according to different people's circumstances and is subject to dynamic changes.

On Tuesday, the State Council joint prevention and control mechanism held a press conference on providing medical services to priority groups. At the conference, an expert from Peking University First Hospital stressed the protection of unvaccinated seniors and seniors with pre-existing conditions. And he also urged suitable seniors to get vaccinated as soon as possible.

In today's post, GRR gathered information from various sources to provide you with a comprehensive picture of vaccinating the elderly in China, including why some of them are reluctant to get vaccinated, the vaccination culture China is attempting to establish, and how to protect the elderly in nursing homes.

The challenge of vaccinating seniors

About 90.37 percent of people of all age groups have finished three doses of COVID-19 vaccination in China. However, only 86.6 percent of the elderly over 60 are fully vaccinated, and for the elderly over 80, the figure is 66.4 percent, according to Xinhua.

When Shanghai was hit hard by COVID from March to June, the mortality risk was reduced by 98.08 percent for people aged over 60 when they finished two doses of vaccines and a booster, by 95.83 percent for those over 80.

A recent press conference of the Joint Prevention and Control Mechanism of the State Council revealed some research. If a person over 80 is unvaccinated, the risk of mortality after infection is about 14.7 percent. With one dose of vaccine, the risk of death decreases to 7.16 percent. And the risk is lowered to 1.5 percent with three doses, according to Xia Gang, an official with the national administration of disease prevention and control.

According to severe cases and death toll in past waves of COVID, vaccines are the key to protecting the elderly, the most vulnerable group in the pandemic.

In Hong Kong, for example, less than 20 percent of people aged over 70 had been vaccinated when the COVID-19 resurgence erupted in February 2022. According to the Hong Kong Department of Health, about two-thirds of the 9,257 deaths over 70 were unvaccinated. For this age group, unvaccinated people are 13 times more likely to die compared with those who had three doses of vaccines.

A study published in《中国疾病预防控制中心周报》China CDC Weekly in August reveals that the full vaccination rate of Singapore's citizens over 70 years reached 95 percent, far higher than Hong Kong's 56.82 percent. And the case fatality rate (CFR) for this age group stood at 0.48 percent, only about one-tenth of that of Hong Kong.

According to Bloomberg, about 93 percent of Japanese seniors aged over 65 had received two doses of vaccine and 90 percent had received a booster. Japan's COVID deaths per capita is 246 per million people, which is the lowest rate among 38 OECD members.

Contrary to countries like Singapore and Japan, China's overall vaccination rate is among the best in the world. However, the data for the senior is not optimistic.

On Dec. 14, China's National Health Commission released a document about giving priority groups an extra dose. The document says that based on the first booster, relevant authorities should start giving the second booster to high-risk groups, people aged over 60, people with serious underlying health conditions and immunocompromised people. How to persuade the elderly to get vaccinated has become an urgent part in China's new battle against COVID.

Building a "vaccination culture"

At the grassroots level, the job of vaccinating the elderly often falls onto social workers and grass-root officials in neighborhoods. Li Qiu works in a neighborhood committee in a city in eastern China. At the end of May 2022, higher authorities asked the committee to increase the first-shot vaccination rate of the elderly to at least 91.2 percent. But back then, the figure was barely above 70 percent, Li told Southern Weekly, a Chinese weekly newspaper based in Guangzhou.

Similarly, at the end of June 2022, Wang Hai, an official of a village committee, also received a notice from higher authorities to boost the first-shot vaccination rate of people over 60 to at least 90 percent. At that time, the vaccination rate in the surrounding villages was generally 40 to 50 percent, according to the newspaper.

Their strategy is to rely on acquaintances. The village cadres take the lead in mobilizing the people around them to get vaccinated, and the vaccinated group would bring their friends and family to the site. In Wang's village, the nursing home would only admit the elderly who had finished three doses of vaccine, which accidentally boosted the vaccination rate.

In Wang's view, the vaccine-averse seniors are thinking about what benefits, such as material incentives, vaccines can bring to them. His village committee give five kilograms of rice to seniors who receive vaccination. But this is hardly appealing compared to rewards like "cash in four figures" in some cities.

Li Qiu's committee also hand out gifts like rice, flour, oil, and local cakes, to the elderly when they get their first shot. However, Li feels that material incentives have a limited effect. "The elderly coming to the vaccination site are still those willing to be vaccinated."

For villagers resisting vaccination, the immune protection provided by the vaccine does not seem to be a sufficient reason. Ultimately, Wang chose the plain "storytelling" method to make sure villagers understand the gains and losses. For example, "Somebody from a nearby village had underlying health conditions. He died of COVID because he was not vaccinated."

A paper from China CDC Weekly suggests that general practitioners be involved in vaccination campaigns. Morepver, the government should clarify vaccine contraindications in the official guidelines timely, and allow the general public to report directly to the AEFI surveillance system (adverse events following immunization), and publish AEFI data regularly to reduce public concerns.

Wang also stated that other than side effects, a range of different reasons make seniors hesitate in front of vaccination. Some are simply too lazy to go to the vaccination site. He believed that we should build a vaccination culture in all age groups, rather than mobilizing the elderly alone. "As a matter of fact, many seniors follow the dynamics in society and they are under the influence of people around them."　

Other than sweeping away the elderly's concerns and mobilizing them to get COVID vaccines, grass-root officials also make vaccination more convenient for them by providing door-to-door services.

According to Xinhua, a medical team in Shijingshan District of Beijing provides door-to-door vaccination services three times a week. The medical team is composed of five to six people. Members are grass-root officials working in local communities and medical workers. They are divided into two groups, and each group can go to 12 households every time.

"We need to conduct health evaluation first, check whether the elderly have pre-existing conditions, examine their medical history, etc. In this way, we assess whether the elderly are suitable for vaccination or not," said Luo Yan 罗琰, doctor from Beijing Rehabilitation Hospital affiliated to Capital Medical University. She adds, "After the assessment, we communicate further with the family. If the family agrees and signs the informed consent, they will vaccinate the senior."

Many places across the country have carried out similar practices. The Jinbi Yayuan community in Baiyun District, Guangzhou provided special COVID-19 vaccination service for people over 60 years. Ms. Liu, aged 63, suffers from rheumatoid arthritis. After making a detailed inquiry about her health condition, medics believed that she was suitable for vaccination, and guided her to receive the third dose.

Li Zizhen, an official from Community Health Service Center of the Dongcheng Sub-district Office in Jieshou City, Anhui Province, said that recently twenty or thirty senior citizens come for the COVID-19 vaccines every day, and the consultation hotline is also popular. The city has also organized vaccine teams equipped with first-aid equipment and medicines to provide door-to-door services at any time.

Multiple places in China are now optimizing measures to help the elderly get vaccinated, including opening "green channels," setting up temporary vaccination sites and vaccination vans, as well as providing door-to-door vaccination services for disabled and semi-disabled elderly people, etc. Medics also bring medical equipment and medicines with them for post-vaccination observation.

China has 267 million people aged over 60. If the vaccination rate rises by one percent, over two million people would be shielded against severe COVID conditions and deaths.

"The Spring Festival is approaching. And vaccines generally take effect in half a month, which means when the spring travel rush starts and people go home for holidays, vaccination will be of great benefit in curbing transmission," said Zhong Nanshan, China's renowned respiratory disease expert.

In boosting vaccination for the most vulnerable, a "vaccination culture" is forming in China. The "vaccination culture" may further facilitate vaccine campaigns and save countless lives. Other than a higher vaccination rate, we may need more measures to protect the elderly in nursing homes. Because the facilities usually have a high living density and some elderly there need the most intense care.

How to protect the vulnerable in nursing homes

When China entered a new stage of epidemic prevention and control. Several renowned epidemiologists, including Zhong Ming 钟鸣, director of the Critical Care Medicine Department at Zhongshan Hospital affiliated to Fudan University, explained to the public how to conduct self-monitoring and how to protect the vulnerable in special facilities.

As one of the most seasoned epidemiologists in China, Zhong has rushed to different places to support local medical forces in battles against COVID outbreaks over the past three years. In his fight with the Delta variant, he dealt with a very tricky situation: taking care of a large number of seniors with high nursing requirements in hospitals at the same time. In the absence of nursing, the mortality rate of the disabled and mentally challenged elderly would shoot up. The final success of the treatment relied on the huge input of local medical workers.

Therefore, Zhong believed that we should make every effort to ensure that the elderly do not leave the environment and people they are familiar with. Permanent residents of nursing homes are highly dependent on the environment, so changing the environment could lead to a bad prognosis. If we have to transfer severe cases from the nursing home to designated hospitals for COVID treatment, Zhong advised that a carer familiar with the elderly's conditions should go along. He argued that the elderly's regular carers know the elderly well, and substituting carers may cause their pre-existing conditions to worsen.

When talking about the current situation in nursing homes, Zhong urged these facilities to maintain relatively strict epidemic prevention and control measures, according to the Paper, a newspaper based in Shanghai. "Under the new circumstances, nursing homes should roll out response plans," said Zhong, adding that nursing homes must try their best to keep the facilities away from the current COVID wave in society, including taking specific measures on regulating family visits as well as materials coming in and out.

Thus, Zhong advised that nursing homes need to have seniors' information, including vaccination status and underlying health conditions. And he has called for getting all eligible seniors vaccinated in multiple occasions.

The expert also urged nursing homes to implement active closed-loop management. First, relatively closed-loop management in special facilities would buy us time for vaccination. Second, even if an outbreak does take place in nursing homes, medical resources will be more abundant if we wait till the current wave of infection in society is over. Old patients can get better treatment when hospitals are not overwhelmed, according to Zhong in a recent interview with Southern Weekly.

"For example, many disabled or mentally challenged seniors cannot eat on their own because of a swallowing disorder. In fact, pneumonia is the most frequent cause of death for the bedridden elderly," said Zhong. He explained that a swallowing disorder will cause food to move into the trachea.

"A nursing worker who has taken care of an old person for a long time knows how fast and how much he eats in one spoon. Because the worker has done the job long enough to know the condition. However, if others come to do the job, like a doctor or a nurse, the patients might choke and develop pneumonia. Considering under a protection level of 2, medical workers may not be very responsive to all sorts of cues," said Zhong. Enditem

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