Covid boosters are critical for older adults. Why aren’t more people getting them?

About 1 in 3 Americans age 65 and older who have completed their first round of vaccinations have still not received their first booster shot, according to the Centers for Disease Control and Prevention. The numbers have baffled researchers, who note that this age group is still at the highest risk of serious illness and death from Covid-19.

The failure to stimulate more of this group has resulted in the loss of tens of thousands of lives, said Dr. Eric Topol, founder and director of the Scripps Research Translational Institute. “The booster program failed from day one,” Topol said. “This is one of the key issues for the US pandemic and it has been poorly handled.”

“If the CDC were to say, ‘This could save your life,'” he added, “that would help tremendously.”

While the initial vaccination with one or two doses is effective in preventing hospitalization and death, immunity wanes over time. Boosters, which renew that protection, are especially important for older people as covid cases rise again, more transmissible ommicron subvariants spread and Americans drop their masks, Topol said.

Some elderly people, who were given priority for the first vaccination in January 2021, are now more than a year after their last injection. Adding to the confusion: The CDC defines “fully vaccinated” as people who have completed an initial course of one or two doses, although an initial booster is considered crucial for expanding covid immunity.

Numerous studies have confirmed that the first booster injection is a crucial weapon against covid. A study of older veterans published in April found that those who received a third dose of an mRNA vaccine were as much as 79% less likely to die from Covid than those who received just two injections.
A central question for scientists in favor of boosters is why rates have stalled among people 65 and older. Surveys have shown that politics and misinformation play a role in vaccine hesitancy in the general population, but that has not been the case among the elderly, who have the highest initial vaccination rate of all age groups. More than 90% of older Americans had completed a first course of one or two doses by May 8.

In contrast, 69% of vaccinated older Americans have received their first booster shot.

Overall, less than half of eligible Americans of all ages have received a booster.

The discrepancy for seniors is likely due to changes in how the federal government has distributed vaccines, said David Grabowski, a professor of health care policy at Harvard Medical School. Although the Biden administration coordinated vaccine delivery to nursing homes, football stadiums and other targeted locations early last year, the federal government has played a much less central role in delivering boosters, Grabowski noted.

Today, nursing homes are largely responsible for encouraging their residents, relying on pharmacies that traditionally hire them to administer flu shots, Grabowski said. And outside of nursing homes, people generally need to find their own boosters, either through clinics, local pharmacies, or primary care providers.

dr. Thomas Frieden, a former CDC executive, said that given the privatized design of U.S. health care, it might in theory make sense to shift responsibility for ongoing Covid immunization from government-sponsored clinics to individual providers. In reality, Frieden said, that approach doesn’t work because “our primary health care system is life-threateningly anemic” and not set up to easily take on a public health mission.

Most health care providers don’t have the technology to safely keep track of which patients have been vaccinated and to schedule follow-up shots, Frieden said. Nor are there any financial incentives for doctors to vaccinate and encourage their patients.

Even before the pandemic, 28% of Americans had no regular source of medical care.
Grabowski said nursing homes in particular need more support. Although less than 1% of Americans live in nursing homes or assisted living facilities, they account for more than 20% of covid deaths. He would like to see the Biden administration resume coordinating the administration of boosters in nursing homes through massive vaccination efforts. “I wish these centralized clinics would go back to boost residents and staff all at once,” Grabowski said. “That seems like a no-brainer to me.”
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The Biden administration praised its continued efforts to vaccinate the elderly. For example, the Centers for Medicare & Medicaid Services sent quality improvement teams to recommend low-vaccination nursing homes. The Medicare program has sent letters to all 63 million beneficiaries encouraging them to receive boosters and has sent millions of emails and SMS reminders.

Still, many health advocates agree that the country has lost the momentum it had during the early months of the covid vaccination campaign.

“There doesn’t seem to be the urgency that we saw with the first shots,” said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care, an advocacy group.

Some researchers attributed the delay to initial disagreement among health leaders over the value of boosters, followed by a staggered rollout. Boosters were approved in stages for different age groups, without the fanfare that usually comes with a single major policy change. The CDC recommended booster shots for people with weakened immune systems in August; then for the elderly in October; for all adults in November; and for children 12 years and older in January.

In addition, while vaccine ads seemed to be everywhere a year ago, government agencies are less vocal about encouraging boosters. “I felt like we were all being hit on the head originally and all roads led to vaccines,” Grabowski said. “Now you have to find your own way.”

For many elderly people, the barriers that can hinder access to private health care in non-pandemic times also exist for boosters. For example, many seniors prefer to walk in to get vaccinated, without an appointment, or to make an appointment over the phone, even though pharmacies are increasingly turning to online scheduling that requires customers to navigate through a multi-layered system. Some seniors also lack ready transportation, a sometimes towering obstacle in rural areas where health clinics can be 20 to 30 miles apart.

“If people have to take two buses or take time off work or take care of their families, people are less likely to get vaccinated,” Smetanka said.

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dr. LaTasha Perkins, a primary care physician in Washington, DC, said she has worked hard to get her family in Mississippi to get vaccinated. Her grandmother agreed to get her first injections in the fall, just as the CDC approved boosters for all adults.

“Finally we got to a place where we got people having two injections, and then we said, ‘Oh, by the way, you need a third,'” Perkins said. “That was shocking to a lot of communities. They’d say, ‘You convinced me to buy in, and now you’re saying two shots isn’t good enough.'”

While national leadership is important, Perkins said, local connections can be more powerful. Perkins has lectured on vaccines at her church. Municipalities are more likely to rely on her medical advice, she said, because she is a tenth member they see every Sunday.

Some communities have been more successful in overcoming reluctance than others. Minnesota has boosted 83% of vaccinated residents age 65 and older, a greater proportion than any other state, according to the CDC.

According to a KHN analysis of CDC data, Dakota County in Minnesota has boosted a greater percentage of vaccinated people age 65 and older than any other U.S. district with at least 50,000 seniors.

Christine Lees, an epidemiologist and public health supervisor for Dakota County, said her department has hired an agency to provide booster shots to residents and staffers in nursing homes and assisted living facilities. The health department runs vaccine clinics at lunchtime and some evenings to accommodate the working people.

The department pulled money from the federal Coronavirus Aid, Relief, and Economic Security, or CARES, Act to buy a mobile vaccine clinic to bring boosters to neighborhoods and mobile home parks. “We all did it last summer and we started it again,” Lees said. “We went to food shelters and libraries. We went out at least once a week to keep those numbers high.”

Community health workers paved the way for vaccine clinics by visiting residents ahead of time and answering questions, Lees said.

Dakota County also used funds from the American Rescue Plan Act to give $50 incentives to people who received the first vaccines and boosters, Lees said. The incentives “were very important for people who might have to pay a little extra to travel to a vaccine site,” Lees said.

Topol said at Scripps it’s not too late for federal leaders to look at what’s working — and not — and restart the booster effort.

“It will be difficult to restart now. But an aggressive, comprehensive campaign for seniors – whatever it takes – is definitely appropriate,” Topol said. “These people are the sitting ducks.”

Phillip Reese, an assistant professor of journalism at California State University-Sacramento, contributed to this report.

KHN (Kaiser Health News) is a national newsroom that produces in-depth journalism on health issues. Together with Policy Analysis and Polling, KHN is one of the three major operational programs of KFF (Kaiser Family Foundation). KFF is an endowed non-profit organization that provides information on health issues to the nation.

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