Age and Disability

The last few categories of determinants which influence vulnerability and risk for pandemic overlap with many of the issues presented in earlier sections. This is indicative of the interaction between the social determinants of health [10]. Age and disability are presented together as determinants of risk for pandemic because they are clustered as variables in the literature for many studies, presumably because the prevalence of disability increases with age. In Canada, in 2001, approximately 3.6 million Canadians self-identified as having a disability, based on the questions posed in the Participation Limitation and Activity Survey (PALS) [127].

Enarson and Walsh [24] identified the elderly as one of 10 high risk populations in Canada, and there is a growing recognition that the needs of the elderly and people who have disabilities are not addressed adequately in most emergency plans [40]. Loss of autonomy, limited financial resources, reduced mobility and social isolation are all factors which lead to vulnerability in both these populations [16, 25]. For anyone who is reliant on other people for personal care and support for daily living, the socio-economic impacts of a pandemic will present significant challenges in securing appropriate supports.

People with disabilities who are reliant on the help of others to perform personal care activities are also at risk during pandemics for a number of reasons [29]. The caregivers of such individuals are often not recognized as essential health care workers and therefore do not receive early doses of the vaccine. The Canadian Pandemic Influenza Plan [59] emphasizes the importance of including people who have different types of disabilities or functional limitations in the pandemic planning process, to ensure plans are inclusive and comprehensive. It should be noted that “disability is not limited to wheelchair users and people who are blind or deaf. Individuals with disabilities include those with one or more activity limitations such as a reduced or inability to see, walk, speak, hear, learn, remember, manipulate or reach controls, and/or respond quickly” [41]. Pandemic plans also often overlook the needs of people with disabilities and emergency communication is rarely accessible for people with vision and/or hearing impairments [29]. People who have communication disorders may also have difficulty responding to warnings, obtaining information, or communicating their needs [59]. Specific conditions which may present functional limitations for communication include, but are not limited to, aphasia, dementia, and stroke, as well as sensory disabilities impacting vision and hearing.

The province of Quebec [76] lists “…elderly people, young people with difficulties and their families or those with pervasive developmental disorders, people who are functionally dependent, people with physical or intellectual disabilities, and people with mental health problems or addictions” as particularly vulnerable during pandemic (p.77). Chen et al. [128] suggest that people with traits that differ from the average person and those who may have difficulty obtaining required services may be vulnerable during emergency scenarios, such as pandemic, and they specifically identify the elderly age cohort as a group at heightened risk.

The elderly are also at a higher risk of influenza due to biological factors. Due to decreased immune system activity, the elderly are at an increased risk of respiratory infections, especially if they live in assisted living facilities [93]. The vulnerability of nursing home residents has been a concern for some time and many studies describe the beneficial effects vaccination can have for this population [129]. The elderly are more vulnerable to secondary bronchial infections like pneumonia, and may also require additional booster vaccinations to ensure their immune systems are properly functioning with the vaccine. In addition to this, if the elderly were to contract influenza, they may be ill for a longer period of time and therefore transmit the virus at a higher rate than the rest of the population [130]. Previous research has shown racial and ethnic disparities in vaccination rates among the elderly [66, 77, 108, 112]. Fiscella et al. [66] asked people over age 65 years if they had been vaccinated against influenza in the previous year, and rates of vaccination among the entire sample were much lower than expected.

A common theme in the literature surrounding vaccination of older populations is that being reminded by a health care practitioner is an effective facilitator for vaccination uptake [77, 112], even in the form of a postcard or a reminder in the mail [114]. Dushoff et al. [131] explain that children are often vectors for transmitting influenza to the elderly and it may be beneficial to vaccinate younger age groups as a strategy to reduce transmission to the elderly.

In a study of older adults with dementia, caregiver distress and depression were found to exert a negative influence on annual vaccination rates [22]. Sambamoorthi and Findley [115] cited health literacy among the elderly as a contributing influence to low vaccination uptake, in addition to racial, financial and convenience barriers. Dementia and other cognitive impairments may also make it difficult to understand important emergency communications during the pandemic [15, 43]. Those with pre-existing psychological disorders may also experience augmentation of symptoms due to the stress of a pandemic [59]. Geographic location of the immunization clinic was also deemed to be a barrier to obtaining the vaccine. Finally, elderly caregivers may not have the opportunity to seek out vaccinations, particularly if this involves travelling and long wait times.