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COVID-19 Booster Uptake ‘Far Too Low’ in Nursing Homes as Winter Surge Returns

New AARP analysis finds more than a 50% increase in cases, as over 2 million residents and staff remain behind on shots


 

Booster uptake in U.S nursing homes remains alarmingly low, with fewer than half of residents and less than a quarter of staff up to date on their shots as of mid-December, a new AARP analysis of federal data shows. The lack of vaccine uptake occurs as another winter surge of the virus infiltrates facilities, increasing the infection and death rates among residents.

The rates have sparked concern among nursing home stakeholders and government health officials, who are calling for increased action.

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“The rates have been steadily climbing, but this number is still too low,” said Centers for Medicare & Medicaid Services (CMS) Administrator Chiquita Brooks-LaSure, on a call with industry stakeholders last week. “As we head further into the winter months and face new variants of COVID-19, getting your residents up to date on vaccines needs to remain your number one priority.”

Between mid-October and mid-December, residents who are up to date on their COVID-19 vaccinations only increased from 40 to 47 percent, leaving more than 600,000 behind on their shots, AARP’s analysis found. Meanwhile, the rate of staff who are up to date has declined by 3 percentage points over the same period. Only 22 percent were up to date as of mid-December, leaving more than 1.5 million workers behind on their shots.

Residents and staff are considered “up to date” once they’ve gotten the bivalent booster, which became available in early September last year, or if they completed their primary vaccination series or had another booster within the past two months.

The analysis shows considerable variation among states’ up-to-date vaccination rates. In Arizona, only 26 percent of residents were up to date, representing the lowest rate in the nation. Meanwhile, South Dakota had the highest percentage of residents up to date, at 76 percent, and California led the way in up-to-date workers, at 43 percent.

But even those top-ranking states aren’t where they should be, said AARP’s Ari Houser, a senior methods advisor and coauthor of the analysis. Across the board, rates of bivalent booster uptake are still “far, far too low,” he said, adding that there’s a lack of urgency. “We’ve been warning for months that cases are likely to rise again, and that residents and staff need the new boosters to maximize protection against the virus. But it’s just not happening.”

Houser said that the rates are particularly alarming, given that the U.S. has entered a historically troubling period: winter. Over the past two years, the largest spikes in cases and deaths occurred during the late fall and early winter.

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And this familiar seasonal surge is seemingly occurring in nursing homes once again, according to the analysis. Rates of cases among residents and staff increased more than 50 percent in the four weeks ending in mid-December, compared with the previous four weeks. The rate of resident cases — 1 in every 17 tested positive — was the highest since February 2022, and has been exceeded only during the peaks of the last two winter surges.

COVID-19 deaths among residents also increased for the second month in a row, with roughly 1,100 reported nationally. The figure represents a 14 percent jump, compared with the previous four-week reporting period. Already, more than 180,000 nursing home residents and workers have died from the virus, accounting for roughly a sixth of the country’s total COVID-19 death toll.

Calls for improvement grow

The federal government contracted with CVS, Walgreens and some other pharmacies to conduct on-site vaccine clinics at most of the nation’s nursing homes in late 2020 and early 2021, and the efforts proved successful in getting residents their primary series of COVID-19 shots quickly. A federal mandate requiring all workers of nursing homes participating in Medicare and/or Medicaid to be vaccinated with a primary series, effective as of early 2022, also greatly helped staff uptake. Both the resident and staff vaccination rates reached almost 90 percent, with many states well above that rate, according to AARP’s analyses.

But no campaign of this scale has been in place for subsequent shots. Also, no part of the federal vaccine mandate requires workers to stay up to date with vaccinations. While some states have issued their own booster mandates for workers, or have helped coordinate administration clinics, the majority haven’t, leaving facilities to work it out on their own. Many operators have reported battling high rates of vaccine hesitancy, a lack of awareness or confusion around the bivalent boosters, a lack of staff to administer the shots, plus pandemic fatigue among their communities.

“We had this very organized campaign for the initial vaccine rollout that, despite some glitches, was very successful in getting those rates up in a rapid way,” said R. Tamara Konetzka, a professor of public health sciences at the University of Chicago. “But that’s not enough,” she said. “Vaccination is not a onetime event, it’s an ongoing process, and I think the process around boosters has just not been organized.”

“[Vaccine] policies cannot remain stagnant,” concluded Konetzka, in a recent JAMA Network Open study she coauthored on COVID-19 in nursing homes. The study found that as newer, more infectious and transmissible variants of the virus have emerged, the original two-dose regimen of the COVID-19 vaccine was no longer associated with lower rates of adverse COVID-19 outcomes in nursing homes. “This suggests that additional booster doses for staff may be needed to effectively manage the pandemic in nursing homes,” the report states.

In late-December, AARP wrote to the CMS, which regulates the country’s 15,000-plus nursing homes who participate in Medicare and/or Medicaid, urging “more action” to increase up-to-date vaccination rates. The letter called out the agency for weakening the enforcement of its COVID-19 staff vaccination requirements and asked for heightened consequences for noncompliance. It also urged increased education on the shots and proactive outreach to nursing homes with low up-to-date rates to establish on-site vaccination clinics.

During the CMS’s stakeholder call last week, officials said 150 on-site clinics were conducted across the country between late November and late December, resulting in over 4,000 residents and over 1,300 staff being vaccinated. Officials said they were continuing to reach out to offer assistance, education and support.

“We really hope you will take these groups up on these offers,” said CMS Administrator Brooks-LaSure. “Getting the updated vaccine is the most important tool that we have to prevent serious illness, hospitalization and death from COVID-19. And nursing home residents, who are often particularly susceptible to severe outcomes from the virus, deserve the highest level of protection that we can offer.”

AARP’s analysis, conducted by the AARP Public Policy Institute and the Scripps Gerontology Center at Miami University in Ohio, draws primarily on data from the Nursing Home COVID-19 Public File by the Centers for Medicare & Medicaid Services. Most nursing homes are federally certified and required to submit data to the government each week.

The ongoing analysis captures data only from nursing homes participating in Medicare and/or Medicaid, not from all long-term care facilities — such as assisted living, independent living, memory care and others — as some other tallies do. An updated analysis will be released next month as new federal data becomes available. Read more about the analysis.

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