As winter looms, western nations have put their faith in booster shots and child vaccination campaigns to fortify their defences against a Covid-19 resurgence.
But health authorities in the northern hemisphere fear the size of any wave during colder months could hinge on how many vaccine holdouts remain among older, vulnerable people.
Officials in Europe and the US, keen to avert the increased burden on hospitals that could accompany a sharp increase in cases, are asking whether their vaccine drives can win over the most hesitant elderly people and have examined the impact of other measures — such as making vaccines compulsory.
Vaccine mandates have largely been credited with boosting uptake rates in younger groups, but several European nations have observed a similar effect among elderly people as well.
A Financial Times analysis of Public Health England data showed it currently took about 800 double doses to prevent one hospital admission in the over-60s over a four-week period, while it took about 25,000 double doses to achieve the same result in the under-18s, because of older age groups’ much greater vulnerability to severe disease.
England ranks alongside countries including Spain, Portugal, Denmark and Ireland as one of the nations with the highest Covid vaccination rates among older groups. More than 13m — about 95 per cent — of over-60s in England have received their first dose, according to PHE. But that still leaves nearly 600,000 vaccine holdouts in that age group, which has accounted for more than 90 per cent of coronavirus deaths.
In the US, particularly the southern states, the picture is even more stark. More than 3m Americans aged over-65 are yet to receive their first jab, including almost one in 10 of those aged over 75. Last month, President Joe Biden lamented the “pandemic of the unvaccinated” on account of the disproportionate pressure vaccine holdouts were putting on hospital wards and intensive care units.
Kevin Schulman, professor of medicine at Stanford University, predicted that the next phase of the pandemic would be “a damn sight easier” in Europe than in the US because of high vaccine uptake rates among elderly people.
Schulman added that the vaccine had become highly politicised, driving a wedge between vaccine sceptics and those who had chosen to embrace jabs.
“We need to depoliticise the vaccine,” said Schulman. “The elderly groups that are not vaccinated are very focused on alternative media, which is delivering conflicting messages. We need to think about how we infiltrate that space with new messages.”
He warned that without finding effective ways to change people’s minds, vaccine holdouts would be converted in “the most tragic way” — by seeing unvaccinated relatives, friends and neighbours fall severely ill with coronavirus over winter.
This effect is already visible in some of the states worst-hit by the highly infectious Delta variant, where images of crammed ICUs swamped local TV news broadcasts over summer.
In Florida, daily first dose uptake among over-65s had fallen to 0.03 per cent by July, but as Delta surged through the state, that figure almost quadrupled to 0.11 per cent a day. Similarly, Mississippi hit a low of 0.03 per cent in early summer before bouncing back to 0.17 per cent daily uptake among over-65s once Delta took hold.
Noel Brewer, professor of health behaviour at the University of North Carolina, said this phenomenon had led to “an almost perfect overlap” between the number of new Covid cases and vaccine uptake rates.
Brewer said the first-dose vaccination drive would show a “last burst of energy” over winter as the combination of continued financial incentive schemes, a surge of infections and a wave of newly introduced vaccine mandates ratcheted up pressure on older people to get the jab.
In Europe, a number of countries have experienced some success by using vaccine mandates.
France, Lithuania and Slovenia all saw daily vaccination rates in people aged over 60 fall from about 1 per cent over spring to roughly 0.1 per cent by summer, before rebounding after vaccine passports were announced.
Arunas Dulkys, Lithuania’s health minister, told the FT that the part of the logic behind introducing his country’s “passport of opportunities”, which came into effect in mid-September, was to prevent older Lithuanians, who have among the lowest life expectancy in the EU, falling severely ill in droves.
Dulkys said vaccine passports were “one of the most important tools” in restraining the pandemic. “Vaccine passports put the power in citizens’ hands,” said Dulkys. “In each society, people exist who would like to free ride. They think ‘we will wait and you will solve our problems’, but the passport engages people as part of the solution.”
Angus Thomson, former head of vaccine confidence and coverage at French pharmaceuticals group Sannofi Pasteur, said France’s passport scheme helped jolt “wait-and-see-ers” into action.
“These people weren’t against vaccination but they weren’t leaping at it feet first,” explained Thomson. “However, when [the vaccine passport] came into play, the decision became a pretty categorical risk-convenience equation even for elderly people.”
“It was somewhere between a nudge and a shove,” added Thomson. “Suddenly, people were faced with: go to a café, don’t go to a café, go out for an aperitif, don’t go out for an aperitif, go shopping, don’t go shopping.”
Italy, meanwhile, has gone further than most countries with vaccine mandates, expanding their reach from hospitality venues to all workplaces, and becoming the first western nation to actively consider wholesale mandatory vaccination.
But so far Italian health authorities have had limited success in swaying hesitant older groups. Some 2.8m Italians aged over 60 are still unvaccinated.
“It’s a series of steps and we’re trying to squeeze as many vaccinated people out of each step,” said Anna Odone, professor of public health at the University of Pavia. “Everything now has to become very personalised to appeal to individuals. That means going door-to-door to find these older people and convince them.”
Odone said mandatory vaccinations remained on the table “as a last resort” but added it would represent “accepting defeat” for public health communication.
If Italy were to pull the trigger on mandatory vaccination, it would join Indonesia, the Federated States of Micronesia and Turkmenistan. “That’s odd company for us to keep,” added Odone.
