key: cord-0714063-yefyy8j1
authors: Loh, Kah Poh; Soto-Perez-de-Celis, Enrique; Mislang, Anna Rachelle; Chan, Wing-Lok; Battisti, Nicolò Matteo Luca
title: COVID-19 vaccines in older adults with cancer: a Young International Society of Geriatric Oncology perspective
date: 2021-05-06
journal: Lancet Healthy Longev
DOI: 10.1016/s2666-7568(21)00060-x
sha: edac394a3cf7459646b6b672c6ba154ce7333382
doc_id: 714063
cord_uid: yefyy8j1

nan

Although older adults (aged ≥65 years) are no more susceptible to SARS-CoV-2 infection than younger adults, they are more likely to develop serious illness and die after they become infected. 1 In addition to age, patients with cancer also have worse outcomes compared with those without cancer. 2 Therefore, these groups of patients should ideally be prioritised for receipt of COVID-19 vaccines. Several COVID-19 vaccines have been developed extremely quickly, with the first vaccine developed in 11 months. However, it has been noted that older adults continue to be under-represented in vaccine trials. For example, in the interim analyses of 11 636 participants enrolled in the AstraZeneca vaccine trials, only 8·4% of participants were aged 56-79 years and 3·8% were aged 70 years or older. 3 Among the 30 351 patients enrolled in the Moderna vaccine trial, 25% of participants were younger than 65 years. 4 Most countries do not exclude older adults from receiving the vaccine; however, there are a few exceptions. In Germany, the Standing Committee on Vaccination initially recommended against the use of the AstraZeneca vaccine in adults aged 65 years and older due to paucity of data in this age group. 5 However, this recommendation was later changed to allow routine use in people aged older than 60 years. On March 30, 2021, routine use in people younger than 60 years was no longer recommended due to concerns about the risk of blood clots. 6 In China, it is recommended that vaccination is postponed for people older than 59 years pending additional safety and efficacy data in this age group. 7 Vaccine trials focusing on older adults are ongoing. 8 The WHO Strategic Advisory Group of Experts on Immunization provided a prioritization roadmap to guide countries in developing public health and prioritisation strategies based on vaccine availability (very limited, limited, moderate) and epidemiological settings (widespread transmission, localised or limited transmission, countries with no reported cases but at risk for an outbreak). 9 New Zealand, for example, uses this strategy when prioritising groups for vaccine. In the context of widespread community transmission, adults older than 65 years and adults younger than 65 years with underlying conditions and disabilities are prioritised first (table; appendix). 10 However, in the context of low or no community transmission or clusters of cases, the priorities change. Most countries use a stepwise approach based on chronological age with prioritisation of certain groups (eg, people living in long-term care facilities, health-care workers, frontline workers) irrespective of comorbidity during initial vaccine rollout. Older adults are generally prioritised before or shortly after health-care workers. Comorbidity, rather than cancer specifically, is prioritised in younger adults.

Prioritisation of vaccination using age groups represents a practical approach that is easier to organise and to effectively communicate to the public according to other criteria such as comorbidities. 11 Although targeting individuals with medical conditions that might predispose them to severe COVID-19 infection could be an even more efficient way to reduce hospital admissions and mortality, prioritising one comorbidity over another is difficult and controversial. Up to twothirds of all adults aged 70 years and older have at least one condition associated with worse COVID-19-related outcomes. 12 The 2017 Global Burden of Disease (GBD) study estimated that, among patients aged 60-90 years worldwide, a third of patients have cardiovascular diseases, 30% have chronic kidney failure, 20% have diabetes, 18% have chronic obstructive pulmonary disease, and approximately 15% have a cancer diagnosis. 12 Therefore, vaccinating all older adults, regardless of their medical history, seems to be the most efficient strategy. Additionally, many countries or territories do not have appropriate registration systems, which means that a significant proportion of patients with comorbidities might not be detected or traced, and therefore vaccination could become inefficient. 11 It is important to note that while eligibility might open for older adults or those with cancer, it remains challenging for any given individual to receive vaccine. In the USA, varying eligibility across states has caused confusion. Older adults also face problems such as Comment e241

www.thelancet.com/healthy-longevity Vol 2 May 2021 scheduling appointments (due to the need to be familiar with technology), knowing vaccination sites, reluctance to wait in long lines due to concerns about COVID-19 exposure, and inability to travel due either to physical limitations or lack of transportation. Additionally, as a result of low vaccine availability, a large majority of older adults and patients with cancer have yet to be vaccinated.

In conclusion, older adults with or without cancer, a high-risk and under-studied group, have generally been prioritised to receive the COVID-19 vaccine, although barriers remain at the individual and health-care system levels. Ongoing efforts to study the safety of vaccines in older adults and more importantly, to ensure equity and justice in COVID-19 vaccine distribution, are of paramount importance. KPL Data sources are provided in the appendix. *Listed in order of prioritisation. †In the context of widespread community transmission but not in the context of low or no community transmission or clusters and controlled outbreaks (as of March 2, 2021, prioritisation is based on low or no community transmission). 

Flinders Centre for Innovation in Cancer, College of Medicine and Public Health

The age distribution of mortality from novel coronavirus disease (COVID-19) suggests no large difference of susceptibility by age

Patients with cancer appear more vulnerable to SARS-CoV-2: a multicenter study during the COVID-19 Outbreak

Safety and efficacy of the ChAdOx1 nCoV-19 vaccine (AZD1222) against SARS-CoV-2: an interim analysis of four randomised controlled trials in Brazil, South Africa, and the UK

Efficacy and safety of the mRNA-1273 SARS-CoV-2 vaccine

Decision of the STIKO for the recommendation of the COVID-19 vaccination and the corresponding scientific rationale

Germany restricts use of AstraZeneca vaccine to over 60s in most cases

As China gives vaccines to other countries but not its elderly, Chinese over 60 ask: what about me? VOA News on China

Safety, tolerability, and immunogenicity of an inactivated SARS-CoV-2 vaccine (CoronaVac) in healthy adults aged 60 years and older: a randomised, double-blind, placebo-controlled, phase 1/2 clinical trial

Roadmap for prioritizing population groups for vaccines against COVID-19

Sequencing the roll out of COVID-19 vaccines

European Centre for Disease Prevention and Control. COVID-19 vaccination and prioritisation strategies in the EU/EEA

Global, regional, and national estimates of the population at increased risk of severe COVID-19 due to underlying health conditions in 2020: a modelling study