Vaccination in Older Adults: Erasure, Barriers, and Hesitancy (Part Three)

By Patricia Harte-Maxwell

The future may not be known, but current examples of vaccination securing life and opening doors exist. For example, vaccinations are recommended for travellers visiting countries where polio is endemic; some schools, like medical programs, and occupations require vaccinations to shadow or work in clinics and hospitals; and, related back to the child, certain vaccinations can reduce the chances of infertility caused directly by HBV or HPV viral infections (in men) or by complications of viral infection.

Where Kafer discusses the issue of the Politics of the Child enabling deferral of change that would benefit disabled people now traded for the ‘curing’ of unborn children later, for the purposes of this blog I look at the Politics of Child in relation to vaccination as the devaluing of older people in exchange for children that are not imaginary but with theoretically longer lives ahead, a shift away from the bodies here and now to phantom bodies (and who most likely will manifest a present-body into the imagined-phantom-body). Essentially, the predominance of vaccine discussions to focus on children rather than adults is a culmination of the reasons explained previously as well as an internalized equating of youth with more life and more worthy life. If the scenario of limited vaccines exists, as it does during the current global pandemic, the central idea of the Politics of the Child as an ideology of futurity persists despite the obvious argument that older populations have been prioritized for vaccination because insuring the most future life years is maintained: because mortality is higher in older adults than other groups, even if middle aged adults have more life years ahead, the vaccine prevents more deaths in older adults and thus preserves more future life years overall (Lloyd-Sherlock). To be sure, the ‘trade-off’ between old and young is itself often imaginary because there is usually not a limited supply of vaccine doses that would warrant a hierarchy of recipients; however, the security of future life, the Politics of the Child in terms of “more healthy, more active, stronger and smarter,” (Kafer 29) itself is not imaginary as on all sides of vaccine debates people argue for the position they feel insures the most and best future life, just as Kafer shows that the Politics of the Child are used by pro-choice and antiabortion campaigns (28). Despite the imaginary ‘trade-off’ between old and young, the Politics of the Child as it applies to vaccination has very real consequences for vaccine culture.

The vital consequence is one of recognition. I have stated so far that vaccine debates focus on children and I have provided some context to suggest why despite vaccinations being available at many ages and vaccination constituting an important if silent component of one’s life well beyond childhood. The focus on children in vaccine discussion has led to two popular narratives: the needlessly dead child and the heroic vaccinator. These are not particularly complex narratives. Both begin with an unvaccinated child. In the needlessly dead child narrative the unvaccinated child, acting as victim and vector, contracts a fatal disease that could have been prevented by vaccination. In the heroic vaccinator narrative the unvaccinated child survives to an age of majority then breaks from the totalitarian rule of a parent or guardian to be vaccinated in secret. The newly and bravely vaccinated person returns to convince their parent/guardian of the value of vaccination and/or saves other unvaccinated persons. These are archetypal narratives that appear in fictional and non-fictional works like dramatic TV shows and news articles.

To clarify, when these narratives appear in non-fictional works, they generally are implied – more specifically the needless death of a child is implied to elicit feelings of sorrow and remorse. News articles from The New York Times and CBS about the 2014-2015 and 2019 Measles outbreaks at Disneyland both imply the death of children by not acknowledging the deaths or lack of deaths from the Disneyland outbreaks, ensuring that ambiguity and fear reign in readers. The NYT article goes further by ending with mortality statistics and suggesting that vaccination is imperative: “Before measles vaccines became widely administered in 1963, about three million to four million Americans a year contracted the disease, and about 400 to 500 died from it” (Hassan). I mention these narratives that I have observed to highlight their commonality in denying a future to unvaccinated persons – an example of the Politics of the Child working for proponents of vaccination. This denial is applied on the surface to the unvaccinated child but the sentiment is far reaching. With the erasure of unvaccinated children by death or by vaccination the possibility of unvaccinated older adults is likewise done away with. Unvaccinated adults become a non-issue – they simply do not exist in a set of narratives in which the future is reserved for, is attainable by, only the vaccinated. The same result, an erasure of unvaccinated adults, is achieved by vaccine discussions that do not include adults or older adults as potentially unvaccinated or vaccine-hesitant populations.

Reserving the future for the vaccinated and ignoring unvaccinated adults is  not only an age problem because vaccination is still a privilege afforded to white, heteronormative, and wealthy groups – the demographic that has been the least mistreated by medical institutions and disadvantaged by policies that have limited and continue to limit access to healthcare. According to researchers from the University of Manitoba, University of Toronto, and University of Guelph who performed a meta-analysis of vaccination studies on 65 and older populations from North America, Asia, and Europe, non-White persons have a decreased uptake of seasonal Influenza vaccines (Okoli et al 9), married individuals have an increased uptake (9), while persons with higher income, and the factors that depend on better socioeconomic status such as higher level of education and health insurance coverage, have increased uptake, (9, 13, 14) regardless of governmental vaccine programs that make vaccines freely available. Besides this, vaccine-hesitant and unvaccinated adults very obviously do exist, in Canada the seasonal Influenza vaccine uptake of adults 65 and older averages about 65% (Okoli et al 2; Pereira et al 487); ignoring this group and their potential concerns constitutes a serious gap in caregiving.

Many have asked why Influenza vaccination for people 65 and older is below the desired amount of 80% in Canada and 75% by the WHO (487), or why as of March 23 only 71% of 80 and older Ontarians have been vaccinated for SARS-CoV-2 (Crawley). The answers are multiple and not purely based in vaccine-hesitancy. In a webinar, “Equity in Vaccination Coverage for All Ages,” hosted by the International Federation on Ageing on March 10, 2021, Dr Peter Lloyd-Sherlock and Dr Carlos Franco-Paredes both described the layered barriers that older adults face in vaccine acquisition. Older adults face difficulties in acquiring transportation to vaccine sites like pharmacies or clinics, an issue that is compounded by scheduling appointments when multiple people may need to be available at once: a driver, a family member, a personal care worker, a long-term facility worker. Some adults are not generally aware of or informed about recommended vaccinations and the schedule for these vaccinations (Eliers 70), which is possibly explained by decreasing numbers of family practitioners, a statistic supported by the previously mentioned study which found that vaccine uptake decreased by 66% in adults 65 and older without a primary-care physician (Okoli et al 17). Other practices that have arisen during the SARS-CoV-2 vaccine rollout have negatively impacted vaccination in older adults. Despite older populations being the first to be vaccinated in Canada and other countries, emergency use vaccines were not immediately known to be safe and/or effective in people 65 and older because clinical study participants in this age group made up a small percentage of total participants. Dr Lloyd-Sherlock brought up a specific example from India where photo ID is required to register for and be vaccination (“COVID-19 Vaccine FAQs.”) but many older adults do not have a state-issued ID because they do not drive or are not active in other ways that require or produce such IDs. In Ontario, 80 and older people may defer being vaccinated because of mass-vaccine sites that, regardless of effort, are exactly the crowded and enclosed spaces people have been told to avoid as well as difficulties in scheduling appointments over the internet (Crawley). While these barriers do not constitute vaccine-hesitancy, that does not mean that people 65 and older do not question or have concerns about the safety and efficacy of vaccinations on top of these difficulties in accessing vaccines.

Pereira et al in a survey of 65 and older adults in Canada found that 6.1% of respondents (n=5014) thought that a more effective Influenza vaccine, like a high-dose vaccine, was necessary for older adults because regular Influenza vaccines were seen to be less effective in this age group (488). Without a high-dose vaccine option, some participants viewed Influenza vaccination as ineffective; still others saw vaccination as unnecessary (487). Eliers found similar results in which some viewed vaccination as an especially painful procedure with little benefit (69). Both Pereira et al and Eliers have noted that perceived risk such as severity of illness or spread to others is important when emphasizing the value of vaccination (Pereira et al 490-491; Eliers 71), which once again leads back to a lack of information regarding vaccine recommendations and reasoning for vaccination as an overall preventive medical procedure for suffering and mortality.

A portion of suboptimal vaccination rates in older adults result from a combination of vaccine-hesitancy, barriers to access, and ignoring older adults in vaccine discussions by removing them from vaccine narratives on all sides of debates as a consequence of traditional and political vaccine culture. Because older adults do not feature in many vaccine discussions, the hesitancy and barriers these people experience is exacerbated and go unchallenged, leading to low vaccination rates for Influenza, SARS-CoV-2, pertussis and pneumococcal pneumonia, or painful conditions like shingles. Low vaccine rates show a gap in the care older adults receive whether they are living at home or in long-term facilities because vaccines can prevent or lessen the suffering of individuals here and now. A greater emphasis needs to be placed on the quality and quantity of life that vaccinations provide for everyone as a recognition of humanity and the right to be relieved from suffering, not just youth and the number of life years ahead. The studies cited throughout have conducted their research with the specific goal of addressing low vaccination rates in older adults by tailoring informational vaccine programs and promotion to the age group. The information that such endeavours provide may reduce vaccine refusal and vaccine hesitancy due to misunderstanding/misinformation in one’s mind, but actual barriers still exist regardless of vaccine stance.  I see the low vaccination rates in older adults as a product of a changing biomedical system that places value in quantity instead of quality: lack of primary care physicians was marked repeatedly as a factor in decreased vaccine uptake and the decrease in primary care physicians is a result of a system that prizes speciality and lavishes specialists with recognition and financial gain; at the same time, new methods of intervention are not always friendly to older adults, such as virtual care appointments that run into the same issues of technological inaccessibility and illiteracy as scheduling a SARS-CoV-2 vaccine appointment online. Low vaccine rates in older adults and other marginalized populations is a symptom of a system lacking in care: care for life and care for quality of life. Reforms in the healthcare system need to be undertaken alongside increased and directed vaccine programs and promotion to increase vaccination rates in older adults for their own sakes.