Protecting older people: a high priority during the COVID-19 pandemic

Recently, the omicron B.1.1.529 wave of the COVID-19 pandemic has caused a substantial impact in several areas in China. In Shanghai, the mortality associated with COVID-19 was low (0—09%), possibly due to the high vaccination rate (more than 90%), among whom 45% received a third dose. However, a lower booster vaccination rate (38%) was reported among older people (ie, aged >60 years).¹ Our survey at 61 metabolic management centres in Shanghai confirmed this finding.² Among 39 498 patients with diabetes, the overall booster vaccination rate was lower in those older than 60 years than those 60 years and younger (36—6% vs 45—0%).² Lower vaccine coverage in older people was also observed in Hong Kong, and nationwide in China, as well as in some South American countries such as Chile.1, 3, 4 Furthermore, during the outbreak, more than 90—0% of COVID-19-related deaths in Shanghai occurred in unvaccinated older people, and 84—6% in Hong Kong occurred in older people who were unvaccinated or received only one dose.3, 5 These data indicate the importance of vaccination in older individuals.

Population ageing is now a worldwide problem. According to the latest UN reports, the proportion of people aged 65 years and older was approximately 10% globally in 2022, and will continue to increase over the next several decades.⁶ In the 2021 report, in China this proportion was 13—5%, and accompanied by an increase in age-related diseases (eg, the prevalence reached 30% for diabetes and >50% for hypertension among older people).7, 8, 9 Therefore, strategies to protect older people against COVID-19 are of the highest priority, not only for China, but also for many low-income and middle-income countries encountering the same difficulties during the pandemic.

To protect older people, several issues should be taken into consideration. First, actions to ease public concerns and promote vaccination implementation in older people are crucial. Our survey found that a history of diabetes-related comorbidities and poor metabolic control before the pandemic were both related to a low booster vaccination rate.² These findings reflect concerns about the possible adverse effects of the vaccine on concomitant diseases in older people. In a society that has embraced Confucianism for over 2000 years, Chinese people cherish filial piety as one of their fundamental values. Older people are usually regarded as the most prestigious members of a community. Therefore, Chinese people tend to accept older people's choice of being unwilling to take vaccines, which include the COVID-19 vaccine. Additionally, many older people and their family members were not motivated to take vaccines because of the well controlled COVID-19 situation in China. These circumstances led to low vaccine coverage among older people at the early stage of the pandemic. As more safety data become available, disclosure of vaccination safety information in a timely manner through official channels is feasible and important. Moreover, experiences from other countries are informative, including prioritising vaccination of older people in the USA and many European countries, mandates in older people in Greece, and linking vaccination to COVID-19 treatment-related costs in Singapore.10, 11

Second, the vaccine needs to be made more accessible to older people. Efforts such as setting up dedicated vaccination sessions for susceptible people and delivering vaccines to the homes of those with disabilities are both helpful.

Third, with the dual burden of population ageing and COVID-19, managing chronic metabolic disease, providing health education and continuous care, and establishing an efficient safety response system are essential. Some pilot chronic disease care centres, such as metabolic management centres based in hospitals and partnered with long-term care services, are such an attempt.¹² This approach is expected to solve medical problems sustainably and enable healthy ageing during the pandemic.

In addition, with rapid mutations of SARS-CoV-2 and potential immune escape of different subvariants, the protection of existing vaccines decreases over time. As such, accelerating vaccine development targeting new variants and simplifying the approval procedure for its clinical use are imperative. Moreover, for older people with vaccination contraindication, seeking alternative ways to create a protective barrier against SARS-CoV-2 is equally important.

Overall, these aspects are thought-provoking, and we should take a holistic approach to protect older people from COVID-19. This is fundamental to completely resume cross-border activities.