Dr. Won Lee began her initial visit to a new homebound patient, Almeta Trotter, last month by asking about her life, her health and how she was managing in her apartment in the Dorchester neighborhood of Boston, shared with her longtime partner and a parakeet.
Eventually Dr. Lee, the medical director of the Geriatrics Home Care Program at Boston Medical Center, raised a key question. “I said, ‘What are your feelings about vaccination against Covid?’”
“I heard that I shouldn’t get it because I take blood thinners” for a heart problem, replied Ms. Trotter, 77.
Not true. Whether Ms. Trotter had misunderstood what she’d heard on television news or had been misinformed, “I told her I had many other patients with the same condition on the exact same medication who have been vaccinated with no problems,” Dr. Lee said.
When Ms. Trotter agreed to the shots — in part because “the news was talking about all these people dying,” in part because her two daughters had gotten them — Dr. Lee dispatched a nurse to vaccinate her at home. She’s scheduled for a second dose this month.
One down and — of the program’s 563 frail homebound patients, most in their 80s and older — about 80 to go.
The effort to vaccinate the nation’s over-65 population represents both a success story and a source of intense frustration. It’s the age group with the highest rate: 92 percent have gotten at least one shot and 82 percent are fully vaccinated. Yet so many remain unprotected.
“It’s pretty darn good,” said William Schaffner, an infectious disease specialist at Vanderbilt University. “But we clearly need to do more in this extraordinarily vulnerable population. They are not safe enough.” With seniors at far higher risk for severe illness, hospitalization and death from Covid-19, he had hoped to see their vaccination rate top 90 percent by now.
Nearly 10 million older people are without full immunization. That not only endangers them, but provides opportunities for the coronavirus to keep mutating in the bodies of those with weak immune systems. It could also complicate the planned distribution of third shots.
Last winter, when the vaccines became available, the older cohort got a head start.
“They were the first in line,” said David Grabowski, a health care policy researcher at Harvard Medical School. Seniors were among those who received priority for appointments, while a federal program brought vaccine clinics directly to nursing homes. And many were inclined to roll up their sleeves.
“A lot of older adults realized they were at risk,” said Dr. David Nace, a geriatrician at the University of Pittsburgh Medical Center who researches infections in older adults. “We have an older population that recalls what it was like before the polio vaccine or the diphtheria vaccine.”
Statistics from the Centers for Disease Control and Prevention showed this population’s vaccination rates soaring through the spring, then hitting a plateau. Among 65- to 74-year-olds, 80 percent were fully vaccinated on July 1, creeping gradually to almost 84 percent by Sept. 1. Among those over 75, about 76 percent were fully vaccinated on July 1 and about 79 percent now.
Those numbers conceal enormous regional variations. Dane County, Wisconsin, which includes Madison, has reached almost universal vaccination for those over 65. But only 75 percent are fully vaccinated in Los Angeles County.
In New York City, rates for those over age 65 range from 80 percent on Staten Island to just 67 percent in Brooklyn. The rate falls below 50 percent in several Alabama counties and below 40 percent in stretches of New Mexico.
Even older people who want the shots can face substantial obstacles. Early on, with local health authorities operating mass vaccination sites, “some older adults couldn’t manage the online registration, or couldn’t get to a center,” Dr. Grabowski said.
Months later, with vaccines widely available, people who are disabled, frail or cognitively impaired may still struggle to access the first or second shot.
That’s particularly true for the homebound, defined as people who leave their homes once a week or less. Their numbers have sharply increased during the pandemic, according to a survey in JAMA Internal Medicine published last month.
Among respondents over 70, about five percent were homebound from 2011 to 2019. In 2020 — likely because of Covid-related public health recommendations — the proportion jumped to 13 percent. More than one-quarter of those didn’t have a cellphone; half didn’t have a computer.
But access isn’t the issue for Dr. Lee’s patients; in February, nurses and doctors started bringing vaccines to their doors. Home medical practices like UCSF Care at Home in San Francisco and Bloom Healthcare in suburban Denver have also vaccinated their patients. About a thousand such programs serve homebound seniors across the country, the American Academy of Home Care Medicine estimates.
Yet even after extended discussions, 14 percent of the Boston Medical Center program’s homebound patients have either delayed or refused immunization.
Understand Vaccine and Mask Mandates in the U.S.
- Vaccine rules. On Aug. 23, the Food and Drug Administration granted full approval to Pfizer-BioNTech’s coronavirus vaccine for people 16 and up, paving the way for an increase in mandates in both the public and private sectors. Private companies have been increasingly mandating vaccines for employees. Such mandates are legally allowed and have been upheld in court challenges.
- Mask rules. The Centers for Disease Control and Prevention in July recommended that all Americans, regardless of vaccination status, wear masks in indoor public places within areas experiencing outbreaks, a reversal of the guidance it offered in May. See where the C.D.C. guidance would apply, and where states have instituted their own mask policies. The battle over masks has become contentious in some states, with some local leaders defying state bans.
- College and universities. More than 400 colleges and universities are requiring students to be vaccinated against Covid-19. Almost all are in states that voted for President Biden.
- Schools. Both California and New York City have introduced vaccine mandates for education staff. A survey released in August found that many American parents of school-age children are opposed to mandated vaccines for students, but were more supportive of mask mandates for students, teachers and staff members who do not have their shots.
- Hospitals and medical centers. Many hospitals and major health systems are requiring employees to get a Covid-19 vaccine, citing rising caseloads fueled by the Delta variant and stubbornly low vaccination rates in their communities, even within their work force.
- New York City. Proof of vaccination is required of workers and customers for indoor dining, gyms, performances and other indoor situations, although enforcement does not begin until Sept. 13. Teachers and other education workers in the city’s vast school system will need to have at least one vaccine dose by Sept. 27, without the option of weekly testing. City hospital workers must also get a vaccine or be subjected to weekly testing. Similar rules are in place for New York State employees.
- At the federal level. The Pentagon announced that it would seek to make coronavirus vaccinations mandatory for the country’s 1.3 million active-duty troops “no later” than the middle of September. President Biden announced that all civilian federal employees would have to be vaccinated against the coronavirus or submit to regular testing, social distancing, mask requirements and restrictions on most travel.
“Families said, ‘My grandmother doesn’t go out of the house,’” Dr. Lee said. “But even if you don’t go out, a family member or a caregiver comes in and can bring illness.” Before the vaccines arrived, her practice lost 28 patients to Covid, she said, and “it was heartbreaking.”
Why the foot-dragging among the population that, as Dr. Grabowski put it, has the most to gain?
The political divide that has led many Americans to resist vaccination is smaller in the older population than in younger groups, but still exists. A July survey by the Kaiser Family Foundation found that among those over 65, only three percent of Democrats said they would “definitely not” get vaccinated, compared with 13 percent of Republicans.
Where seniors get information also plays a role, according to a recent study by health services researchers at the University of Iowa, using a national survey of Medicare beneficiaries from late 2020.
At that time, when vaccines were unavailable but imminent, 13 percent of respondents said they definitely or probably would not get vaccinated, the survey found, citing primarily fear of side effects and mistrust of government. About one-quarter were unsure.
“Individuals who depend on social media, the internet, friends and family and health care providers were more likely to express a negative vaccination intent, compared to those who used ‘regular news,’” said Divya Bhagianadh, one of the study’s co-authors.
Health care providers? At the time, “there was substantial indecisiveness among health care providers themselves,” said Kanika Arora, the survey’s other co-author.
Now, with the country about to start mobilizing for third shots, “I’m worried about the potential of a free-for-all,” Dr. Grabowski said. “Will the effort to give the booster crowd out the people who need their first or second shot? Will there be lines and schedules that make it harder” for seniors to get vaccinated?
Vaccine mandates from employers and schools will not affect most older adults. Bridging this particular vaccination gap will take continuing efforts by federal and local health officials — bringing vaccines to individual homes and neighborhood senior centers, providing transportation to pharmacies or clinics, revisiting nursing homes and including their staffs, enabling primary care doctors to offer vaccines in their offices.
Ms. Trotter, for one, seems glad to be getting her shots. The first dose of the Moderna vaccine, she reported, caused no side effects at all.
“My arm didn’t even hurt,” she said.