COVID-19 non-vaccination among older adults in China: a nationwide survey based on the China Health and Retirement Longitudinal Study (CHARLS)
Authors: Zhao Yaohui , Wang Gewei , Yao Yao , Wang Yafeng , Gong Jinquan , Meng Qinqin , Wang Hui , Wang Wenjin , Chen Xinxin 
Published: December 2022

Abstract
China has a lower rate of vaccination among older adults and those who have chronic conditions and functional disabilities. As China has recently ended the zero-COVID policy, understanding the factors behind low vaccination rates among these vulnerable populations can inform immediate policy priorities to save lives for China and offer lessons for the world at large. We used the fifth wave (2021-22) of the China Health and Retirement Longitudinal Study (CHARLS), which represented mainland Chinese 45 and older. Vaccination status was updated in the summer of 2022, reflecting the current situation because very few additional vaccinations were administered afterward. For those who were unvaccinated, self-reported reasons were recorded. Using regression analysis, we investigated the determinants of non-vaccination, including demographics, functional status, and chronic conditions. In addition, two-thirds of the respondents had their vaccination status recorded twice in 2021 and 2022, allowing us to examine changes in vaccination rates in the recent year, zeroing in on the effects of the government's most recent vaccination campaign. Finally, we corroborated the regression results using self-reported reasons for non-vaccination in both years. A total of 12900 participants were included in the analysis. By the summer of 2022, the weighted COVID-19 vaccination rate among older Chinese people (≥60 years old) was 92.3%, with 88.8% having completed the primary series and 72.7% having received boosters. Only 72.0% of the oldest-old (≥80 years old) had completed the primary series, and 47.1% had had boosters. Regression analysis showed that participants who were older, female, unmarried, registered with urban Hukou residence, functionally dependent, and comorbid with chronic conditions were less likely to receive COVID-19 vaccines. A significant increase in vaccination rates among ethnic minorities, older adults, rural residents, and those with chronic conditions and functional dependency was observed in the year after the winter of 2021 when the government started to push for universal vaccination. The self-reported reasons for non-vaccination in 2022 were contraindications (48%), advanced ages/frailty/health conditions (21%), problems in accessing vaccines (18%), concerns about side effects or efficacy (9%), and having never heard of COVID-19 vaccine (6%). Nevertheless, as China has ended the zero-COVID policy, many older people, especially the oldest and those with chronic conditions and disabilities, have not yet been fully vaccinated with the primary series or booster doses, exposing them to the danger of infection. Therefore, health authorities should immediately abandon the previous practice of refusing to vaccinate those with chronic conditions, change people's mistaken perceptions of contraindications and side effects, and improve access to vaccines. Most importantly, China should strengthen public trust in vaccines by making information transparent regarding the vaccine's protection rates and side effects.