More than a year after COVID-19 vaccines became widely available in nursing homes nationwide, the facilities have gone a long way toward blunting the virus’s threat to their most vulnerable residents.
Today, 88% and 89% of nursing home residents, as well as 89% of employees, are fully vaccinated. This is higher than the rate for the general population. Despite the fact that cases rose to new records in January, the death rate among nursing home residents was only a fraction of the level seen during the surge at 2020.
However, with the pandemic now in its 3rd year, thousands have found a way to avoid being vaccinated. They claim medical exemptions from a federal mandate affecting health care workers that was put into effect this year.
According to a survey, almost 20,000 nursing home workers in the United States have applied for a medical exemption. ProPublicaAnalysis of federal data. That rate is three times that of nursing home residents, a notably vulnerable group, who didn’t get the vaccine for medical reasons.
Dr. Jana Shaw, a pediatric infectious diseases specialist at SUNY Upstate Medical University (Syracuse), said that she believes medical exemptions have been misused. “Previous research has shown, as we started mandating vaccinations, people will find avenues to get out of the obligation of getting vaccinated,” she said.
The Centers for Disease Control and Prevention discovered that for every million doses of vaccines in the United States, there have been six cases that were severe enough to prevent the administration of the vaccine.
Neglecting to vaccinate staff can lead to serious consequences. A group of researchers from U.S universities found that nursing home staff could have had a greater effect on COVID-19 deaths by increasing their vaccination rates. This was in response to a two-month-long study. Since the outbreak, more than 150,000 people have died in nursing homes and their staff.
According to CDC data, approximately 1.7 million of the 1.9 million workers in nursing homes across more than 15,000 U.S. locations have been fully vaccinated since shots became available in 2021. More than 500,000 of these workers have been vaccinated since the federal mandate was announced. This raises the national vaccination rate to 89% from 65% in September.
However, staff vaccination rates can vary from one state to the next. According to CDC data, one in six nursing homes has a vaccination rate below 75%. For example, nursing homes in Rhode Island have a vaccination rates of 99%, while those in Montana have a rate of 77%.
In the meantime, the number of staff members who claim a medical exemption has increased from approximately 9,400 when it was announced to just below 20,000 as of March. This data is provided by nursing homes, and may contain errors.
Many of the employees claiming medical exemptions cluster in the same nursing homes: In 27 of Ohio’s more than 900 nursing homes, over 15% of employees have claimed medical exemptions — more than in any other state. And in California, where only 4% of the state’s nursing home workers are unvaccinated, 23 facilities have claimed exemptions for 15% or more of their staff.
More than a dozen facilities have reported that a third to half of staff have indicated that they have a medical excuse to forgo being vaccinated. Scientists are puzzled by these clusters, according to Tim Leslie, a George Mason University researcher who has studied vaccination rates.
“That suggests some level of organization to achieve that outcome,” he said.
Even those who have had a mild allergic reaction to the COVID-19 vaccination, the CDC recommends that they continue the course. The CDC recommends that only people with severe allergies to the vaccine or any of its ingredients should avoid the vaccine.
A far larger group — 164,000 workers — has declined to get the vaccine for another reason, which can include a religious objection. The federal government doesn’t track the number of religious exemptions.
Between medical exemptions and workers who refuse the vaccine for other reasons, more than 1 in 5 nursing home workers in Montana, Wyoming and Ohio have yet to get vaccinated — the highest rates in the country, according to the CDC data.
The American Health Care Association/National Center for Assisted Living made a statement stating that long-term care facilities are committed to getting their staff vaccinated. It also noted that employees who have not been vaccinated should take precautions to prevent infection spreading.
“Each hesitant staff member has their own unique reason(s) for choosing not to get the vaccine,” the statement said. “Despite rampant misinformation spreading online, the industry has made significant progress. We have found that it takes a multi-pronged, persistent approach to help increase vaccination rates.”
Facilities with unvaccinated workers face graduated penalties that could result in losing federal funding as a “final measure,” according to the Centers for Medicare and Medicaid Services, the federal agency that regulates nursing homes. The agency has the data to identify hospitals with unusually high medical exemption rates. However, the agency has instructed state inspectors not to inspect these exemptions during special inspections but to only review them during routine visits. It may take months before some facilities are visited.
CMS has instructed inspectors to not examine religious exemptions.
Residents are concerned about the lack of vaccination and possible abuse of exemptions. They also fear that nursing home workers may not be vaccinated.
“If you don’t really believe it should be a mandate, don’t make a mandate,” said Tony Chicotel, a staff attorney with California Advocates for Nursing Home Reform. “If you do think it should be a mandate, then enforce it.”
In a statement, a CMS spokesperson said that the agency “remains pleased by progress to-date” and that its goal is to bring nursing homes into compliance rather than discipline facilities. It said, too, that exemptions “could be appropriate in certain limited circumstances.”
“No exemption should be provided to any staff for whom it is not legally required or who requests an exemption solely to evade vaccination,” the statement said.
State regulators have cited at least one facility for an employee who claimed a false medical reason for forgoing the vaccine. Premier Washington Health Center was cited for a deficiency after an employee received a medical exemption from multiple sclerosis. The condition is not among those the CDC lists as qualifying for an exemption; the employee was later granted a different exemption, according to the state’s inspection report.
Premier Washington officials didn’t respond to requests for comment.
According to its websites, NexCare WellBridge Senior Living operates 20 Michigan facilities that had previously reported large numbers of exemptions. The company reported that over 500 of its 3,300 employees had requested a medical exemption as at February 27. Only 32 residents in those facilities didn’t get the vaccine because of medical reasons as of that date.
After ProPublica asked, the company updated its data. The company’s facilities are now reporting 54 medical exemptions across 10 facilities; 16 facilities are now reporting no medical exemptions.
Holli Titus, a company spokesperson, said in a statement that exemption requests “are not indicative of the nursing home, but of our country’s (and certain regions’) overall vaccine hesitancy.”
“NexCare and WellBridge remain confident that state surveyors will find our vaccination records in order and in compliance with federal regulations,” she said, adding later that the reporting process for vaccinations “caused confusion” among nursing home companies. The company “will continue to evaluate the reporting process and make adjustments if more clarification becomes available.”
Leslie, a researcher in health, said that people who are not willing to get vaccinated will find ways around mandates. After the state eliminated a personal belief exemption for vaccines, California schoolchildren were able to observe this. According to his research, the rate for medical exemptions almost tripled in the following year.
Leslie discovered that the increase was even greater in counties with the highest personal exemption rates. This suggests that parents who were reluctant to have their children vaccinated found doctors willing to grant them medical exemptions.
“We were surprised at the level of medical exemptions, and we were concerned that they had turned into another avenue for hesitant parents,” he said.
The nation’s nursing homes will soon face another challenge: waning immunity of those who have received COVID-19 vaccines. The U.S. Food and Drug Administration approved second boosters for those 50 years and older, as well as for immunocompromised adults. Many nursing home residents and staff have yet to receive their first booster shot.
44% of nursing home staff have not received a booster shot. This is partly due to delays in their first vaccinations. 69% of nursing home residents, on the other hand, have received their first booster.
CMS stated in its statement that workers who have completed the initial vaccination series are considered fully vaccinated. This is the same definition that the CDC uses. Boosters remain optional. It did not state if boosters might be needed in the future.
Dr. Brian McGarry, a health services researcher at the University of Rochester Medical Center in New York who has studied the effectiveness of COVID-19 vaccines in nursing homes, called lags in administering boosters to residents a “policy failure,” especially when compared with previous efforts to quickly get residents vaccinated in early 2021.
“The right time to do it would be before the omicron wave, and we missed the boat on that,” he said.
While that wave is now fading, most U.S. municipalities have relaxed coronavirus restrictions. Experts warn that a more transmissible subvariant may be the dominant strain. This is leading to fears of a new surge.
“The mandate was the last push,” Shaw, the New York physician, said. “I don’t think we have much more left.”