Key nursing home staff lag in COVID-19 vaccination, study shows

Attendant with older woman in wheelchair
Attendant with older woman in wheelchair

National Guard, Michael Baltz / Flickr cc

A study yesterday in JAMA Internal Medicine finds that substantially higher proportions of US nursing home residents are vaccinated against COVID-19 than health workers, with certified nursing assistants (CNAs), who perform the vast majority of direct resident care, lagging considerably.

A team led by a researcher from the University of Rochester in New York analyzed National Healthcare Safety Network nursing home–level data and other public data through Jul 18.

Sixty percent of staff and 81.4% of residents, on average, from more than 14,900 nursing homes were fully vaccinated. Mean vaccination rates were lowest among CNAs (49.2%) and registered and licensed practical nurses (61.0%), while therapists, physicians, and independent practitioners had 70.9% and 77.3% coverage, respectively.

COVID-19 vaccination has had an important role in lowering infection and death rates in US nursing home residents, but low staff vaccine coverage poses a risk of introduction and spread of the virus in facilities—especially in the milieu of more transmissible variants, according to the authors.

"Maximizing vaccination coverage among nursing home staff and residents is critical because of the extreme vulnerability of this population to COVID-19," they wrote.

For-profit status, other factors

After adjustment, relative to nonprofit facilities, for-profit nursing homes were tied to a decrease of 2.5 percentage points for staff vaccination rates and 3.3 percentage points for residents. Vaccine rates rose 1.4 percentage points in staff and 1.2 percentage points in residents for each additional Medicare star rating.

Longer tenure was also linked to increased vaccination rates among staff; an increase of 10 percentage points in staff with long tenure was associated with increases of 1.5 and 0.6 percentage points in vaccination among staff and residents, respectively.

Nursing homes with higher percentages of non-White staff and residents were associated with lower vaccination coverage for both staff and residents.

Influence of county vaccination rate, voting margin

Vaccination rates rose 2.7 and 1.4 percentage points in staff and residents, respectively, for each 10-percentage-point increase in county-wide adult vaccination coverage. And a 10-percentage-point increase in Republican vote margin in the 2020 presidential election was tied to a drop of 1.4 percentage points in staff vaccination rates.

While the study found enhanced vaccine coverage in nonprofit nursing homes and those with higher Medicare star ratings and longer-tenured staff, the researchers said this finding suggests that "facilities are also subject to broader challenges to vaccine acceptance in the community because facility coverages were strongly associated with county-wide vaccination coverage and staff coverage was strongly associated with 2020 presidential election voting patterns."

The study also revealed the scope of vaccine refusal in nursing homes, correlates of vaccine uptake, and the types of facilities most likely to be affected by the future Department of Health and Human Services requirement that facilities mandate staff COVID-19 vaccination or risk losing Medicare and Medicaid reimbursement, the authors noted.

Reform of CNA pay, benefits

In an editor's note on the study, Eric Ward, MD, and Kenneth Covinsky, MD, MPH, both of the University of California at San Francisco, observe that infected CNAs are highly likely to spread the virus to residents during close-contact activities such as bathing, dressing, grooming, and feeding.

"Physical distancing is impossible," they wrote. "For this reason, nursing homes would be the most sensible place to introduce a vaccine mandate, because unvaccinated nursing home staff present an imminent risk to the vulnerable residents in their care." 

Ward and Covinsky also said that CNAs have a positive influence on resident care while working very hard for low pay, with few key benefits such as sick leave.

"We believe low voluntary vaccination rates among CNAs suggests a failure of nursing home owners to effectively partner with their most essential workers and provides one more indication of the need to improve the pay and working conditions of this group," they wrote.

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