En español | When the Centers for Disease Control and Prevention (CDC) recommended last month that residents and staff of long-term care facilities be among the first to receive COVID-19 vaccines, Sondra Norder breathed a sigh of relief.
The president and CEO of St. Paul Elder Services in Wisconsin has seen 100 residents contract COVID-19 across her two campuses over the course of the pandemic. Twenty-eight have died.
"The trauma we have been through, the isolation we have been through, the demand physically and mentally over the last 10 months — we've just been disproportionately impacted,” she says. “I don't think there's anybody more deserving of having this vaccine on board as soon as possible, so that we can start to heal from this."
With COVID-19 deaths in long-term care accounting for 37 percent of the country's coronavirus fatalities — some 133,000 — almost all states have followed the CDC's guidance in pushing long-term care residents and staff to the very front of their vaccine lines.
But actually getting shots into arms of those residents and staff isn't happening nearly as swiftly or seamlessly as planned. So far, just over 950,000 residents and staff of long-term care facilities have received the first of two necessary shots, according to the CDC.
Most of those are likely to have gone to residents and staff of nursing homes, as states generally granted priority to nursing homes over assisted living and other long-term care settings. But with roughly 2.3 million residents and full-time staff in nursing homes, it appears fewer than half have received first inoculations.
And although more than 4 million doses have been distributed for use in long-term care more broadly, only 22 percent have actually been administered.
The federal program tasked with vaccinating the vast majority of America's long-term care residents and staff has been vexed by logistical hurdles and miscommunication. Vaccine hesitancy among staff has emerged as a major issue. And reports that side effects may be felt more after second doses than the first raise concerns about more staff shortages when resources are needed most.
Adding more worry is the extreme level of community spread, with more than a quarter-million new cases and near or above 4,000 deaths across the U.S. on recent days, setting records for the pandemic. Increased community spread means more nursing home outbreaks.
"Even though there's light at the end of the tunnel there” thanks to vaccines, Norder says, “the lights are all still blinking red for us.”
A slow start
Unlike the delivery of most COVID vaccines, which the federal government is handing off to individual states, the feds are spearheading vaccinations in nursing homes. Through its Pharmacy Partnership for Long-Term Care Program, the government has contracted with CVS, Walgreens and other pharmacies in certain states to supply and administer vaccines at no cost to long-term care residents and staff at their facilities.
The government says that 99 percent of the nation's roughly 15,600 nursing homes have registered with the program. In 20 states, every single home has signed up. CVS is partnering with over 40,000 facilities, including nursing homes, assisted living communities and other types of long-term care settings, to provide vaccines to up to 4 million residents and staff. Walgreens is partnering with roughly 35,000 facilities to provide vaccines to up to 3 million more.
"We could have every nursing home patient vaccinated in the United States by Christmas,” Health and Human Services (HHS) Secretary Alex Azar said in mid-December, describing the program.
But as of Jan. 11, only 937,028 long-term care residents and staff have received first doses of a COVID vaccine through the program, according to the CDC's COVID Data Tracker. While that's likely an undercount due to reporting lags, the federal partnership has clearly fallen far behind initial targets.
Meanwhile, West Virginia, which opted out of the federal program and instead used local pharmacies to administer vaccines, became the first state in the country to complete its first round of long-term care vaccinations on Dec. 30.
"It's amazing and it's far ahead of any other state in the nation,” West Virginia Gov. Jim Justice said in a December news conference announcing that first-round vaccinations would be complete in all of the state's 214 long-term care facilities by the new year. “That's 100 percent of our long-term care facilities that we will have offered vaccines to in our state before some other states have even gotten started.”
Even in West Virginia, only about 55 percent of nursing home workers actually took up the offer for a vaccine, according to Martin Wright, who leads the West Virginia Health Care Association, as reported by the Associated Press.
"We know that it should be better"
Army Gen. Gustave F. Perna, chief operating officer of Operation Warp Speed, the federal program to develop and distribute COVID vaccines, has said that the Christmas and New Year's holidays, major snowstorms, and providers still becoming familiar with cold-chain storage and vaccine administration are all factors behind the slow rollout of long-term care vaccinations.
Moncef Slaoui, scientific adviser of Operation Warp Speed, said in late December, “We know that it should be better and we're working hard to make it better.”
Getting consent from nursing home residents who can't give it on their own due to medical conditions can also delay the scheduling of on-site vaccination clinics. “We are working to organize a discussion with the leadership of CVS and Walgreens, with our nation's governors, to make sure that there's a lot of clarity about the process there,” Azar said.
These efforts follow a communication lapse between the government and CVS in mid-December. Azar said CVS mistakenly thought the administration had asked pharmacies to wait till Dec. 21 to start vaccinating in long-term care communities.
CVS and Walgreens recently announced that they are on track to complete administration of first doses in their partnering skilled nursing facilities by Jan. 25. And Perna said he's confident the program is now experiencing “positive momentum,” with clinics, mainly in nursing homes, increasing to 4,000 nationwide per week.
But others, including Mike Wasserman, past president of the California Association of Long Term Care Medicine — which represents doctors, nurses, pharmacists and others in the industry — are skeptical.
"First we heard that all facilities are going to have [personal protective equipment]. They still don't,” he says. “Then we heard all nursing homes are going to have testing machines. A lot of those machines are still sitting on shelves in facilities that haven't known how to use them effectively. Now we heard every nursing home resident is going to be vaccinated by Christmas, and Christmas passed, and we're only getting started.”
It's still not known when assisted living and other long-term care facilities enrolled in the federal program will be done with their first shots.
Staff skepticism about shots
Vaccine hesitancy, particularly among long-term care staff, is another big obstacle. In Ohio, one of the few states that started vaccinating nursing home residents and staff before Dec. 21, roughly 60 percent of nursing home workers have declined to receive a COVID-19 vaccine, Gov. Mike DeWine said in late December, while roughly 80 percent of residents have agreed to receive one.
Richard Feifer, chief medical officer at Genesis HealthCare, which operates more than 325 skilled nursing and assisted living facilities across 24 states, is seeing a similar trend. “Vaccination acceptance among residents is actually very, very high and their own decisions or the decisions of their health care proxies are generally favorable,” he says. “The acceptance among staff varies.… People have questions about the vaccine. Not all people who are eligible are health care experts.”
Staff members are worried about the side effects, according to a survey of long-term care workers by public health officials and Indiana University. It found that among the 55 percent of workers in Indiana who said they would decline a vaccine when offered one, 70 percent cited side effects as the primary reasons for rejection.
If workers are hourly employees with no sick leave or benefits, which many long-term care staff are, they may not be able to afford to get sick from side effects. Certified nursing assistants, who make up the overwhelming majority of care workers at nursing homes, make less than $15 per hour on average, and getting to work is often their top priority.
Genesis has launched messaging campaigns to educate staff, residents and their families on vaccine development, authorization, and the safety and efficacy data behind the COVID-19 vaccines. Feifer hopes his social media campaigns, Q&As with physicians and videos of Genesis leaders getting their shots will “convince them of what we believe, which is that accepting the vaccine is a very, very important thing."
St. Paul Elder Services is doing the same, says Norder, organizing virtual town halls with the company's medical director and sharing experiences from nearby facilities that have hosted vaccination clinics. “By sharing that knowledge with everybody, we can pick away at some of those myths out there about vaccines,” she says.
At St. Paul Elder Services’ first vaccination clinic, 86 percent of residents received shots offered to them. Only 66 percent of staff members did the same.
One, two, three, then what?
There are also fears that facilities will run out of time. Pharmacies in the federal program are contracted to schedule three on-site clinics at each long-term care facility. If residents or staff miss or skip a first dose during the facility's first or second clinic, they may lose their chance to get vaccinated through the program.
Inoculating too many workers with their second doses at one time, meanwhile, could lead to staffing shortages. In the Pfizer and Moderna vaccine trials, participants reported feeling worse side effects — mainly fatigue, headache, muscle aches, chills, joint pain and possibly some fever — after their second dose. This could lead to lots of staff calling in sick at once, straining a facility's ability to look after residents when nearly 30 percent of nursing homes nationwide report recent staff shortages.
Deborah Veit, executive director of a not-for-profit independent living, assisted living and memory care facility in Minnesota called Oak Meadows, worked with Walgreens to ensure it can provide additional visits, spreading out staff injections. “Staff shortages are something we cannot endure,” she says.
Wasserman says the federal program needs to be more accommodating (he sits on the board of AARP charitable affiliate Wish of a Lifetime). “Instead of a one-size-fits-all, rigid approach,” he says he wants a “more flexible plan that might allow the facility to do its own vaccinations over the course of a week.”
At Genesis, very few staff members have developed side effects from the first shot. But Feifer, the chief medical officer, worries about what happens after the three pharmacy visits are complete. “There will still be patients who will subsequently need vaccinations, and there will still be staff who are newly hired who will need vaccination,” he says, “and so protecting nursing homes beyond the first three visits is still an issue.”
So is simply vaccinating nursing home residents and staff by the end of February.