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How older adults with chronic diseases can assess whether to get the Covid-19 vaccine

Recently, a number of readers have asked me if older relatives with these conditions should be vaccinated. This is a question for medical experts and I have asked for advice from several. Everyone strongly suggested that people with questions contact their doctors and discuss their individual medical conditions.

Question: My 80-year-old mother has chronic lymphocytic leukemia. For several weeks, her oncologist would not tell her “yes” or “no” about the vaccine. After much pressure, he finally replied, “It does not work for you, your immune system is too compromised to form antibodies.” She asked if she could take the vaccine anyway, just in case it might provide some protection, and he told her he was done discussing it with her.

First, some basics. Older adults generally responded extremely well to the two Covid-1

9 vaccines that have received special permission from the Food and Drug Administration. In large clinical trials sponsored by drug manufacturers Pfizer and Moderna, the vaccines achieved significant protection against significant disease with an effect on older adults from 87% to 94%.

However, individuals 65 and older undergoing cancer treatment were not included in these studies. As a result, it is not known what degree of protection they can get.

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Dr. Tobias Hohl, Director of Infectious Diseases at the Memorial Sloan Kettering Cancer Center in New York City, suggested that three factors should influence patients’ decisions: Are vaccines safe, will they be effective, and what is my risk of becoming seriously ill from Covid- 19? In terms of risk, he noted that older adults are the people most likely to become seriously ill and die from Covid, accounting for about 80% of deaths to date – a compelling argument for vaccination.

In terms of safety, there is currently no evidence that cancer patients are more likely to experience side effects from the Pfizer-BioNTech and Moderna vaccines than other humans. In general, “we are confident that these vaccines are safe for (cancer) patients”, including elderly patients, said Dr. Armin Shahrokni, a geriatrician and oncologist from Memorial Sloan Kettering.

The exception that applies to everyone, not just cancer patients: people who are allergic to Covid-19 vaccine components, or who experience severe allergic reactions after getting a first shot, should not get Covid-19 vaccines.

Efficacy is a consideration for patients whose underlying cancer or treatment suppresses their immune system. In particular, patients with cancer of the blood and lymph nodes may experience a blunt response to vaccines along with patients undergoing chemotherapy or radiation therapy.

Even in this case, “we have every reason to believe that if their immune system works at all, they will respond to the vaccine to some degree,” and that is likely to be beneficial, said Dr. William Dale, president of supportive care medicine and director of the Center for Cancer Aging Research in the City of Hope, a comprehensive cancer center in Los Angeles County.

Balancing the timing of cancer treatment and immunization may in some cases be a consideration. For those with serious illness who “need treatment as soon as possible, we should not delay (cancer) treatment because we want to preserve immune function and vaccinate them” against Covid, said Hohl of Memorial Sloan Kettering.

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One approach may be to try to time Covid vaccination “between cycles of chemotherapy, if possible,” said Dr. Catherine Liu, Professor of the Department of Vaccine and Infectious Diseases at the Fred Hutchinson Cancer Research Center in Seattle.

In new guidelines published late last week, the National Comprehensive Cancer Network, an alliance of cancer centers, called for patients undergoing active treatment to be given priority to vaccines as soon as possible. A notable exception: Patients who have received stem cell transplants or bone marrow transplants should wait at least three months before receiving vaccines, the group recommended.

The American Cancer Society’s medical and scientific director, Dr. William Cance, said his organization is “strongly in favor of vaccinating cancer patients and cancer survivors, especially older adults.” Given the lack of vaccine, he also recommended that cancer patients receiving Covid-19 receive antibody therapies as soon as possible if their oncologists believe they are good candidates. These infusion therapies, from Eli Lilly and Co. and Regeneron Pharmaceuticals, rely on synthetic immune cells to help fight infections.

Question: Should my 97-year-old mother in a nursing home with dementia even get the Covid vaccine?

The federal government and all 50 states recommend Covid vaccines to long-term care residents, most of whom have Alzheimer’s disease or other types of cognitive impairment. This is an attempt to curb Covid-related illness and death that has swept through nursing homes and assisted living facilities – 37% of all covide deaths since mid-January.

The Alzheimer’s Association also strongly encourages immunization against Covid-19, “both for people (with dementia) living in long-term care and those living in the community,” said Beth Kallmyer, vice president of care and support.

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“What I think this question is trying to ask is ‘Will my loved one live long enough to see the benefit of being vaccinated?'” Said Dr. Joshua Uy, medical director at a Philadelphia nursing home and geriatric fellowship director at the University of Pennsylvania’s Perelman School of Medicine.

Potential benefits include not getting sick or dying from Covid-19, having visits from family or friends, engaging with other residents and participating in activities, Uy suggested. (This is a partial list.) Since these benefits may begin to appear a few weeks after residents of a facility are fully immunized, “I would recommend the vaccine to a 97-year-old with significant dementia,” Uy said.

Minimizing suffering is an important consideration, said Dr. Michael Rafii, Associate Professor of Clinical Neurology at the University of Southern California’s Keck School of Medicine. “Even if a person has end-stage dementia, you will do everything you can to reduce the risk of suffering. And this vaccine gives individuals a great deal of protection against suffering from severe Covid,” he said.

“My advice is that everyone should be vaccinated, no matter what stage of dementia they are in,” Rafii said. It includes dementia patients at the end of their lives in hospice care, he noted.

If possible, a loved one should be on hand to be reassuring, as a person wearing a mask and wearing a needle may cause anxiety in dementia patients. “Let the person administering the vaccine explain who they are, what they do, and why they wear a mask in clear, simple language,” Rafii suggested.

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Question: I’m 80 and have type 2 diabetes and an autoimmune disease. Should I get the vaccine?

There are two parts to this question. The first has to do with “comorbidities” – having more than one medical condition. Should older adults with comorbidities receive Covid vaccines?

Absolutely because they are at higher risk of getting seriously ill from Covid, Dr. Abinash Virk, an infectious disease specialist and co-chair of the Mayo Clinic’s Covid-19 vaccine rollout.

“Pfizer’s and Moderna’s studies specifically examined people who were older and had comorbidities, and they showed that vaccine responses were similar to (that) of people who were younger,” she noted.

The second part has to do with autoimmune diseases like lupus or rheumatoid arthritis, which also puts people at higher risk. The concern here is that a vaccine may trigger inflammatory reactions that may aggravate these conditions.

Philippa Marrack, president of the Department of Immunology and Genomic Medicine at Denver Jewish National Health, said there is no scientifically rigorous data on how patients with autoimmune conditions respond to Pfizer and Moderna vaccines.

So far, the reasons for concern have not emerged. “More than 100,000 people have received these vaccines now, including some who probably had autoimmune disease, and there has been no systematic reporting of problems,” Marrack said. If patients with autoimmune disorders are really concerned, they should talk to their doctors about postponing immunization until other Covid vaccines with different formulations become available, she suggested.

Last week, the National Multiple Sclerosis Society recommended that most patients with multiple sclerosis – another serious autoimmune condition – receive Pfizer or Moderna Covid vaccines.

“Vaccines are unlikely to trigger an MS relapse or worsen your chronic MS symptoms. The risk of getting COVID-19 far outweighs any risk of getting MS relapse from the vaccine,” it said in a statement.

KHN (Kaiser Health News) is a non-profit news service covering health issues. It is an editorially independent program of KFF (Kaiser Family Foundation) that is not affiliated with Kaiser Permanente.

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