Ontario’s Community-Dwelling Older Adults Who Remain Unvaccinated Against COVID-19

Background

Older age is one of the greatest risk factors for COVID-19 mortality.¹ An estimated 93% of the 6.8-million Canadians aged 65 years and older live in their homes in the community, with the remainder living in congregate care settings such as long-term care (LTC) and retirement homes. Canadian national data from June 9, 2021 shows that 16,719 (65.4%) of all fatal COVID-19 cases were among adults 80 years of age and older and most of them (55.9%) were women (n = 9,347).²

Eight weeks after the start of Ontario’s COVID-19 vaccination rollout, 92% of LTC home residents were vaccinated with at least one vaccine dose leading to an estimated relative reduction in SARS-CoV-2 incidence of 89% and COVID-19 mortality of 96%.³ We know less about the success of Ontario’s COVID-19 vaccine rollout among community-dwelling older adults living in the community.³ There have also been concerns about the inaccessibility of the vaccine rollout for some older adults.⁴ Appointments at mass immunization clinics require online booking or long-wait times by telephone, and pop-up clinics operate on a drop-in basis which can result in lengthy and often queues that are designed for specific age groups. There may also be language and transportation barriers. These challenges may be insurmountable for older adults who lack adequate social support networks, including access to a regular primary care physician to assist them with this process. These challenges may be even greater for those living alone or not speaking English.

Questions

Who are the Ontario community-dwelling older adults who have not received their first dose of a COVID-19 vaccine as of June 7, 2021, and what improvement has there been in first dose vaccination rates between April 26 and June 7, 2021?

Is having a primary care physician associated with COVID-19 vaccination in community-dwelling older adults?

What are the characteristics of neighbourhoods where older adults who remain unvaccinated against COVID-19 live?

Findings

In Ontario, there were 2,696,565 older adults (65 years and older) living in the community as of January 1, 2021. The majority of these individuals (53.8%) were women, and 24.5% were 80 years of age or older. The overall first dose COVID-19 vaccination rate for this group was 83% as of June 7, 2021.

Vaccination Coverage Among Those 80 Years of Age and Older

Among all Ontario age groups, vaccination rates have improved least between April 26 and June 7, 2021 for those 80 years of age and older. In the six-week period between April 26 and June 7, 2021, vaccination rates increased among all eligible Ontarians, yet this increase was lowest in those aged 80 years and older. Those aged 80 years and above are most at risk and continue to have a lower vaccination rate than those in LTC homes (97%). Further, this oldest group had the lowest increase in vaccination rate among all older age groups over the six-week period.

Community-Dwelling Older Adults Without an Assigned Primary Care Physician

Community-dwelling older adults without an assigned primary care physician had lower covid-19 vaccination rates. Table 2 describes the assignment of Ontario community-dwelling older adults to primary care physicians by sex and age group. The majority (82.7%) of older adults were rostered to a primary care enrollment model (i.e., Family Health Group or Family Health Organization), a percentage that was slightly higher in women (women = 83.4% vs. men = 81.9%). An additional 11.5% of older adults had a solo primary care practitioner. A total of 156,096 (5.8%) of Ontario community-dwelling older adults had no contact with a primary care physician in the prior two years and were classified as having no regular primary care physician.

Figure 1 illustrates COVID-19 vaccination rates among community-dwelling older adults by primary care physician assignment, sex, and age as of June 7, 2021. The change in first dose vaccination rate by primary care physician assignment between April 26, 2021 and June 7, 2021 is listed in Appendix 1. Only 45.9% of older adults with no regular primary care physician had received one dose of COVID-19 vaccine, compared to 76.8% of older adults with an assigned primary care physician and 86.5% for those rostered to a primary care practice. Similar trends were observed for both men and women, and for all age groups. The negative impact of not having an assigned primary care physician or being rostered to a primary care practice on vaccination rates was greatest among those who were 80 years of age and older.

COVID-19 vaccination rates were lower for those living in neighbourhoods with the highest risk of SARS-CoV-2 infection, which also have the most material deprivation and highest ethnic diversity.^5-7

Table 3 compares the first dose COVID-19 vaccination rates of older adults by deciles of neighbourhood risk of SARS-CoV-2 infection. Overall, vaccination rates were lower in older adults residing in neighbourhoods with a higher risk of SARS-CoV-2 infection. This trend was most pronounced among individuals with no regular primary care physician. In this group, vaccination rates varied from a low of 28.4% in neighbourhoods with the highest risk of SARS-CoV-2 infections to a high of 62.5% in neighbourhoods with the lowest risk of SARS-CoV-2 infections.

Table 4 explores first dose vaccination rates within quintiles of neighbourhood-level material deprivation. Material deprivation is a dimension of the Ontario Marginalization Index.⁷ Vaccination rates were lowest in neighbourhoods with higher material deprivation; this pattern was consistent for men and women, for all age groups, and for older adults with a primary care physician. Vaccination rates for older adults with no primary care physician assigned remained low, regardless of neighbourhood-level material deprivation.

Table 5 explores first dose rates of vaccination across the quintiles of neighbourhood level ethnic diversity. Among those residing in the neighbourhoods with the most diversity, vaccination rates were lower compared with those residing in neighbourhoods with the least diversity. This same pattern was observed irrespective of sex, age, and primary care physician assignment, although, it was most pronounced among older adults with no regular primary care physician. In this group, vaccination rates were 24.7% in the most diverse neighbourhoods increasing to 64.4% in the least diverse neighbourhoods.

Figure 2 shows the unvaccinated rate by primary care physician assignment and the proportion unvaccinated with their first dose in Ontario community-dwelling older adults by primary care physician assignment as of June 7, 2021.

An estimated 54.1% of older adults without a regular primary care physician are unvaccinated compared to only 13.5% of older adults rostered to a primary care practice. Yet, because most older adults in the province are rostered to a primary care practice, the largest percentage of unvaccinated older adults (65.8%) are still cared for within a primary care practice.

Interpretation

While the number of unvaccinated community-dwelling older adults decreased over the six-week period between April 26 and June 7, 2021, it is concerning that vaccination rates among those aged 80 years and above appear to be plateauing, especially since they are at very high risk for poor outcomes following COVID-19 infection. Specifically, there has only been a 4% improvement in first dose vaccination rates among this age group during the study time period. Further, the majority of this unvaccinated older age group are women.

To date, first dose COVID-19 vaccination rates among Ontarians aged 65 years and older were lowest in neighbourhoods at highest risk of SARS-CoV-2 infection, those that have the most material deprivation, and neighbourhoods that were most ethnically diverse. This indicates residual inequities in COVID-19 vaccination, despite the Ontario hotspot vaccination strategy.

These inequities were most pronounced among the 6% of older adults who had no regular primary care physician. Older adults without a primary care physician may miss the benefit of having their primary care physician assist them through the vaccination process, for both first and second doses.

Access may be a major reason why older adults, particularly women in the oldest age group, remain unvaccinated. Most older people are not vaccine hesitant;⁸ they simply may be unaware of how to access the vaccine, unable to manage the booking process, or unable to get to a vaccination clinic to be immunized. Access may be a particular issue for older women who are more likely than men to live alone and may not have someone to care for them, making it more difficult to organize a vaccine appointment and get to the vaccination site. We do know that among LTC homes in Ontario, 97% of residents are vaccinated.⁹ These findings suggest that vaccination rates for older adults in the community may be much higher if the vaccine was made more accessible to them.

While it is important to look at the inequity in access to vaccination experienced by those without a primary care physician, it is also important to recognize that the vast majority of older adults living in the community are part of a primary health practice. As such, among all unvaccinated older adults, the largest unvaccinated group (65.8%) are cared for within a rostered primary care practice. Therefore, tactics to target vaccinations to the unvaccinated older adults require increased collaboration with primary care providers who have important roles in addressing vaccine hesitancy in their primary care practices. This means moving from providing vaccinations at mass vaccination sites to working with primary care physicians to identify those in their practices who are unvaccinated and provide these older adults with vaccine access through smaller mobile outreach clinics, administration in physician’s offices, and when needed in individual homes.¹⁰

For primary care physicians and practices to support their older patients in getting vaccinated, they need accurate and up-to-date lists of their unvaccinated patients. At present, this essential information is not available to primary care physicians and asking physicians to call all their patients to determine who is and is not vaccinated is not feasible. Primary care physicians will need support to do this tailored vaccine outreach and to make vaccines available to their older unvaccinated patients. Family physicians caring for patients rostered to a primary care practice will receive curated lists of their patients who have been vaccinated.  The fact that the Pfizer vaccine can now be stored in fridges for up to 31 days as well as the large number of Moderna vaccines now available,^11,12 combined with improved access and accurate, up-to-date lists of unvaccinated patients will facilitate making vaccines more available from the offices of primary care practitioners and for outreach to older adults in their practice who may require home visits.

For the 18.5% of unvaccinated older adults without a primary care physician, other tactics are required. First, mobile outreach clinics have been very successful in bringing vaccines to the large numbers of older people living in naturally occurring retirement settings (NORCs) who may not be able to get to mass vaccination clinics.¹³ These efforts need to continue. NORCs are apartment, condo, co-op, and social housing buildings with at least 30% of their residents being 65 years of age and above, and with at least 50 older persons per building. They differ from LTC and retirement homes which are purpose-built for older adults.¹⁴ To ensure that NORC mobile outreach clinics are targeting buildings where older adults remain unvaccinated, NORC-level vaccine coverage data have been prepared and shared with Ontario’s 34 Public Health Units (PHUs).

Further, some unvaccinated community-dwelling older adults may be unable to leave their homes or reluctant to leave their homes due to concerns about becoming infected with SARS-CoV-2. This illustrates the importance of working together with community agencies and knocking on doors to bring vaccines to individuals with information provided in the languages that they speak, especially since we found that older adults residing in Ontario neighbourhoods with the highest ethnic concentration had the lowest first dose vaccination rates.¹⁵

Finally, there is a population of older adults who do not have a regular primary care provider and who may be socially isolated. This includes many older women, who may be without someone to advocate on their behalf to help arrange for vaccinations.

COVID-19 has made existing gaps in our healthcare system visible, particularly for older Ontarians. Our findings demonstrate that a substantial proportion of community-dwelling older adults, particularly women in the oldest age groups, remain unvaccinated with even a first dose against COVID-19. These results also show that a group of these most vulnerable older adults have no primary care physician, and this group is much more likely to be unvaccinated. Our findings can inform the development of urgently needed tactics to improve COVID-19 vaccination among Ontario community-dwelling older adults who remain at a high risk of severe COVID-19 outcomes.

Methods Used for This Science Brief

Study Population and Design

We used a cross-sectional study design to quantify the COVID-19 vaccination rate among all community dwelling older women and men in Ontario.

Data Sources

Data for this analysis were obtained through linked health administrative datasets using unique encoded identifiers and analyzed at ICES. ICES is an independent, non-profit research institute whose legal status under Ontario’s health information privacy law allows it to collect and analyze health care and demographic data, without consent, for health system evaluation and improvement. We used the Registered Person’s Database (RPDB) to identify individuals alive and eligible for the Ontario Health Insurance Plan (OHIP) and aged 65 or older as of January 1, 2021. We then excluded individuals without a health care encounter (date of last contact) within the last 9 years and those identified as living in a LTC home. We identified these individuals using recent health service transactions (e.g., OHIP physician billings, Ontario Drug Benefit (ODB) Plan claims) and Resident Assessment Instrument (RAI) assessments from the Continuing Care Reporting System (CCRS). For all individuals included, the last recorded postal code in the RPDB was used to determine their FSA (for definition of incidence deciles, or their dissemination area, for the ON-MARG index). Eight FSAs with less than 200 individuals were excluded from the analysis.

We used a combination of datasets (Ontario Laboratory Information System (OLIS), Public Health Case and Contact Management (CCM) Solutions and testing data from laboratories within the COVID-19 Diagnostic Network) to determine the cumulative incidence of SARS-CoV-2 cases between January 23, 2020 (the date of the first reported case within these data) and March 28, 2021 for each FSA. We ranked FSAs based on their cumulative incidence of SARS-CoV-2 infection among residents living outside of LTC homes within each FSA and grouped FSAs into deciles based on this rank order.^5,6Each decile has 10% of the Ontario population (~1.5 million individuals) and represents the neighbourhood risk of SARS-CoV-2, where 1 = highest incidence neighbourhoods and 10 = lowest incidence neighbourhoods.

Information on the administration of COVID-19 vaccines was obtained from provincial COVaxON data and was reported as of both April 26, 2021 and June 7, 2021. Physician billing claims under Ontario’s Health Insurance Plan (OHIP) along with data from the Client Agency Program Enrolment (CAPE) dataset were ascertained to assess contact with a primary care provider.

Outcomes

The primary outcome was the proportion of older adults receiving at least one dose of a COVID-19 vaccine.

Variables

COVID-19 vaccination rates were reported by various individual-level factors including age, sex, and primary care assignment. Assignment to a primary care physician was categorized into three groups. Individuals rostered to a primary care practice through a specific primary care enrollment model (e.g., Family Health Group or Family Health Organization) were categorized as being “rostered to a primary care practice.” Older adults not identified as being rostered but who received care from a primary care physician within two-years (prior to June 7, 2021 for latest results and April 26, 2021 for earlier results) were categorized as having an “assigned primary care physician.” Those without a visit to a primary care physician within two-years were categorized as having “no regular primary care physician.”

We ranked FSAs based on their cumulative incidence of COVID-19 infection among residents living outside of LTC facilities within each FSA and grouped FSAs into deciles based on this rank order.^5,6 Each decile has 10% of the Ontario population (~1.5 million individuals) and represents the neighbourhood risk of SARS-CoV-2, where 1 = highest incidence neighbourhoods and 10 = lowest incidence neighbourhoods. Material deprivation and ethnic concentration (diversity) are two dimensions of the Ontario Marginalization Index and are derived from census variables at the dissemination area level.⁷ Material deprivation is closely connected to poverty, and it refers to inability for individuals and communities to access and attain basic material needs. The indicators included in this dimension measure income, quality of housing, educational attainment and family structure characteristics.⁷ Ethnic concentration refers to high area-level concentrations of people who are recent immigrants and/or people belonging to a ‘visible minority’ group.⁷

Analysis

We reported vaccination rates by the variables detailed above. Subgroup analyses were performed by age groups, sex, and levels of assignment to a primary care physician.