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.
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.
“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.”
Dr. Lee, a specialist in geriatric care, said she lost 28 patients to Covid before the vaccines became available.Credit…Kayana Szymczak for The New York Times
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.