Joan Phillips, a certified nursing assistant in a Florida nursing home, loved her job but dreaded the danger of going to work in the pandemic. When vaccines became available in December, she jumped at the chance to get one.
Months later, it appears that danger has faded. After the rollout of covid vaccines, the number of new covid cases among nursing home staff members fell 83%—from 28,802 for the week ending Dec. 20 to 4,764 for the week ending Feb. 14, data from the Centers for Medicare & Medicaid Services shows.
New covid-19 infections among nursing home residents fell even more steeply, by 89%, in that period, compared with 58% in the general public, CMS and Johns Hopkins University data shows.
These numbers suggest that "the vaccine appears to be having a dramatic effect on reducing cases, which is extremely encouraging," said Beth Martino, spokesperson for the American Health Care Association and National Center for Assisted Living, an industry group.
"It’s a big relief for me," said Phillips, who works at the North Beach Rehabilitation Center outside Miami. Now, she said, she's urging hesitant co-workers and anyone else who can to "go out and take the vaccination."
After a brutal year in which the pandemic killed half a million Americans, despite unprecedented measures to curb its spread—including mask-wearing, physical distancing, school closures and economic shutdowns—the vaccines are giving hope that an end is in sight.
Noting that more than 3 million doses of vaccine have been doled out in nursing homes, CMS issued new guidelines Wednesday allowing indoor visits in the facilities, even among unvaccinated residents and visitors, under most circumstances.
National figures on health care worker infections in other settings are hard to come by, but some statewide trends look promising. In California and Arkansas, health care worker covid cases have dropped faster than for the general public since December, and in Virginia the number of hospital staffers out of work for covid-related reasons has fallen dramatically.
Research in other countries suggests that vaccines have led to big drops in infection. A study of publicly funded hospitals in England indicated that a first dose was 72% effective at preventing covid among workers after 21 days and 86% effective seven days after the second shot. At Sheba Medical Center—Israel's largest hospital, with over 9,600 workers—170 staff members tested positive from Dec. 19, the first day the vaccine was offered, through Jan. 24. Of those who tested positive, only three had already received both doses of the vaccine, according to The Lancet.
Lost on the Frontline, a yearlong data and reporting project by KHN and The Guardian, is investigating over 3,500 covid deaths of U.S. health care workers. The monthly number has been declining since December, but deaths often lag weeks or months behind infections.
Along with other health care workers, nursing home staffers and residents were first in line to get vaccines in December because elderly people in congregate settings are among the most vulnerable to infection: More than 125,000 residents have died of covid, CMS data shows, while over 550,000 nursing home staff members have tested positive and more than 1,600 have died.
Yet the vaccination rate among staffers is far lower than that of residents. When the first clinics ran from mid-December to mid-January, a median of 78% of nursing home residents took a dose, while the median for staff was only 38%, according to the Centers for Disease Control and Prevention. Now several nursing home associations say the rate of staff vaccination has been climbing, based on informal surveys.
While vaccines are "contributing to the observed declines in COVID-19 cases in nursing homes, other factors, like effective infection prevention and control programs/practices," are also at play, CDC spokesperson Jade Fulce said.
Vaccine uptake by nursing home residents has been "very promising," said Dr. Morgan Katz, a specialist in infectious diseases at Johns Hopkins University who is advising covid responses in nursing homes. "I do think this is a huge contributing factor” to the drop in staff cases.
"When the immune system is activated more quickly" due to vaccination, "the virus is not able to multiply in your body and your respiratory tract," Katz said. So, having even one or two vaccinated people in a building can slow transmission.
Another factor, Katz said, is that "many nursing homes have already experienced large outbreaks—so there are probably a significant proportion of residents and staff who are already immune." Also, covid rates have fallen nationally after a spike from holiday travel and gatherings in November and December, so staff members have less exposure in their communities.
But "even though we’re seeing a really wonderful turn in the number of cases," she said, "we need to remember that as long as the staff is 50 or 30% vaccinated, they remain vulnerable, and they’re also putting incredibly vulnerable long-term care residents at risk."
Vaccination efforts are racing against time as new covid variants circulate and some states dramatically relax covid restrictions, making it easier for the virus to spread.
During the second week in February, 2,850 nursing homes still reported at least one new covid-positive test result for a staff member, CMS data shows.
When this happens, residents suffer, said Lori Smetanka, executive director of the National Consumer Voice for Quality Long-Term Care. She said she's hearing of cases in which one positive covid test result sends a facility into lockdown, preventing families from visiting their loved ones.
The New Jersey Veterans Memorial Home at Menlo Park endured a major outbreak last year in which over 100 workers contracted covid and over 60 residents and a certified nurse assistant, Monemise Romelus, died. Shirley Lewis, a union president representing CNAs and other workers, said it was traumatizing. Still, only about half of workers there have taken the vaccine, Lewis said, and one is out sick with covid.
"A lot of my members are not too excited about taking this vaccine because they’re afraid," Lewis said.
Some workers want to wait a little longer to see how safe the vaccine is, she said. Others tell her they don't trust the vaccines because they were developed so quickly, she said.
Other staffers "feel like it’s an experimental drug," Lewis said, "because as you know, Blacks, Latinos, other groups have been used for experiments" like the Tuskegee syphilis study, she said. She said her members are mostly Black or Hispanic.
Certified nursing assistants, who make up the bulk of long-term care workers, have historically been less likely to get flu vaccines than other health care workers, noted Jasmine Travers, an assistant professor of nursing at New York University who studies vaccine hesitancy. Nursing homes typically don't have nurse educators, who address worker concerns about vaccines in hospitals, she said, and CNAs also face structural barriers such as limited internet access. Nursing homes tend to be hierarchies commonly led by white staffers, while about 50% of CNAs, at the bottom of the power structure, are Black or Hispanic, and carry mistrust and different attitudes toward vaccination, she added.
With the covid vaccine, some are afraid they'll have to take sick time to miss work and don't want to burden their co-workers, who are already short-staffed, Travers said.
Vaccine hesitancy is higher among 30- to 49-year-olds, rural residents, and Black and Hispanic adults, according to KFF. Hispanic adults are less likely than white adults to say they will “definitely” get the covid vaccine, as are Black adults who work in a health care setting. Black adults have been disproportionately burdened by the pandemic and left behind in the vaccination rollout because of barriers stemming from structural racism.
Low vaccine uptake among long-term care workers has been a concern nationally—so much so that LeadingAge, a national group representing not-for-profit long-term care facilities, held a virtual town hall about vaccine safety this month with the Black Coalition Against COVID-19.
The event, which drew over 45,000 viewers, was geared toward Black long-term care workers.
Dr. Reed Tuckson, co-founder of the Black Coalition Against COVID-19, said viewers raised concerns about fertility, pregnancy and contraindications. He said the event also had "a lot of provocateurs" who insisted, "It’s all a myth. It’s all a lie."
His group plans to hold more public informational sessions aimed at Black audiences.
"There is no question that the three vaccines that we now have available to us are extraordinarily safe and tremendously effective," said Tuckson, a former public health commissioner in Washington, D.C.
The nursing home industry has set a goal of having 75% of staff members vaccinated nationwide by the end of June.
A Vaccine Mandate?
Most nursing homes have not mandated vaccinations, industry officials say, for fear of losing staff members. Because the vaccines were authorized on an emergency basis, liability is also a concern.
Juniper Communities, which runs 22 long-term care facilities in four states and employs almost 1,300 people, had 30 workers leave the job after it mandated vaccines, according to Dr. Lynne Katzmann, president and CEO.
"At the end of the day, if you can make a choice to promote well-being and prevent illness, that's the choice we want to make," she said.
Greenbrier Nursing and Rehabilitation Center in Arkansas made the vaccine mandatory, but because of medical exemptions it hasn't led to 100% vaccination.
However, Greenbrier has seen a significant drop in covid infections since vaccinations began. In late November and early December, over 60% of staff members tested positive, according to Regina Jones, Greenbrier’s director of nursing. After the staff started receiving the vaccine in late December, four workers who had already received a dose tested positive but were asymptomatic.
Hesitancy Doesn't Mean Refusal
Tuckson said he's seeing a "dramatic decrease" in vaccine hesitancy based on surveys of Black audiences. He has heard "a hunger for scientifically valid information delivered to them by trusted sources," he said. "It's not as if their opinions are locked in stone."
Staff participation rates are rising with each round of vaccines, said Martino, the nursing home industry spokesperson.
At the Los Angeles Jewish Home, Chief Medical Officer Dr. Noah Marco said his staff has done "everything we could to counterbalance the nonsense out there on social media that has contributed to vaccine hesitancy," including producing videos and a weekly newsletter.
"The vaccine may have some unknown side effects," he recalled telling workers, "but we know the virus kills."
About 80% of his staff of 1,600—which includes workers in nursing homes and other settings—are vaccinated, he said, along with 99% of residents. No nursing home residents have contracted covid since Jan. 13, he said.
In southwestern Ohio, Kenn Daily runs two Ayden Healthcare nursing homes. About half his staff and 85% of residents got vaccinated by mid-February, he said, and they haven't had a case of covid since. Still, he said, vaccine resistance persists among younger staffers who read misinformation online.
"Facebook is the bane of my existence," Daily said. Workers tell him they worry that "they’re going to microchip me," or that the vaccine will change their DNA.
Now that time has passed since the initial rollout, Daily said, "I’m hoping to put a little pressure on my staff to step up and get vaccinated." His message: "It’s working, guys. It’s working very well."
KHN data editor Elizabeth Lucas contributed to this report.