More than 4,770 COVID-19 cases and 700 COVID-related nursing home deaths might have been prevented in the United States over just a two-month period this summer had more nursing home staff been vaccinated, according to a new study.
The findings, published Wednesday in the New England Journal of Medicine, found that in counties with a high prevalence of infections, nursing homes with the lowest rates of staff vaccination had more than twice the COVID-19 cases among residents and nearly three times the number of COVID-19 deaths compared to nursing homes with the highest staff vaccination rates.
The disparities were consistent despite different rates of vaccinations among residents, the study found.
“The driver of cases, and ultimately fatalities, is staff,” said David Grabowski, a professor of health care policy at Harvard Medical School, and a coauthor of the study, which included data from more than 12,360 nursing homes nationwide.
“It’s important you have staff vaccinated because they are really the vectors here, they are the ones who bring it into the facility,” he said.
The study comes as the nation is on edge about Omicron, a new COVID variant that appears even more transmissible than the Delta strain. Grabowski and his colleagues launched their research in mid-June, just as Delta was poised to explode across the United States.
Massachusetts has one of the highest rates of staff vaccinations in the country, just behind Maine and Rhode Island, with roughly 97 percent of nursing home workers receiving their shots, federal data show. But there is concern about potentially waning immunity among staff and a low uptake rate of booster shots.
President Biden’s national vaccination mandate for health care workers — including those in nursing homes — to be fully vaccinated by Jan. 4 is tied up in the courts. Federal data show that roughly 75 percent of nursing home workers nationwide are fully vaccinated, with wide disparities among states.
The researchers classified nursing homes into four equal groups, based on rates of staff vaccinations, from lowest to highest, as of mid-June. Those in the bottom tier averaged 31 percent of staffers vaccinated and those in the highest group averaged about 83 percent vaccinated. Then they determined the number of COVID cases among residents and staff, as well as the number of COVID-related resident deaths, per 100 beds in a facility, between mid-June and Aug. 22.
They also considered the prevalence of COVID in each nursing home’s county during that stretch. In counties with the highest rates of COVID-19, they found that the lowest staff vaccination rates were linked to roughly one additional resident death for every five nursing homes.
“That’s a lot more deaths, per 15,000 nursing homes across the country,” Grabowski said.
A majority of nursing home staff in Massachusetts completed their first round of vaccinations by late February, and some recent studies suggest that waning immunity can lead to more severe COVID cases and hospitalizations, particularly among already frail people.
The most recent state data, from Nov. 28, show that 41 percent of eligible nursing home staff, and 78 percent of eligible residents have received a booster, despite recommendations in September from the Centers for Disease Control and Prevention that people over 65, as well as those living in long-term-care facilities and people working in such high-risk settings, including nursing homes, get the added shot six months after their primary vaccination.
“We are strongly urging all eligible staff, residents, and their families to get the COVID-19 vaccine booster as soon as possible as this continues to be the number one tool for controlling and preventing the spread of the virus,” Tara Gregorio, president of the Massachusetts Senior Care Association, which represents nearly 400 senior care facilities, said in a statement.
The CDC still defines fully vaccinated as the two-dose series, or one shot of the Johnson & Johnson vaccine, and has not formally included a booster in that regimen.
“Fortunately, these breakthrough cases are commonly asymptomatic and not typically resulting in hospitalization or death,” Gregorio said. “As a result of our surveillance testing and screening programs, we are able to quickly detect infections, isolate, and, if necessary, treat infections using monoclonal antibodies.”
Nursing home researchers not involved in the new study said its findings are sound, and sobering.
“There are still fundamental issues of easy access” to shots for certified nursing assistants, some of the lowest-paid nursing home workers, said Vincent Mor, professor of Health Services, Policy and Practice at Brown University School of Public Health.
He said the assistants, the army of workers who do the brunt of hands-on care in the facilities, often work multiple jobs and miss out on opportunities to get a booster shot. Others, like some Americans, mistrust the vaccines.
“There are people all over the country who don’t believe in coronavirus or that vaccines work, and just because you are a nursing home staff person doesn’t mean you will be immune to disinformation,” Mor said.
Simon Johnson, an economics professor at MIT Sloan School of Management who advised the state’s nursing home industry in the early days of the pandemic, said the study’s findings underscore a broad social contract.
“Everyone in the community has the responsibility for COVID in the nursing homes,” Johnson said. “I hear a lot of young people saying, ‘Why should I get vaccinated? If I get COVID, I won’t get sick.’ But part of that reason is, it protects nursing home residents. It’s a social responsibility.”
Nursing home administrators say one of their biggest challenges is a critical staffing shortage in the industry, similar to many other areas of health care right now. Some administrators had worried the state COVID vaccine mandate for staffers would prompt many to quit. That didn’t happen, though some administrators say they lost a few over the mandates and worry that a required booster may be the tipping point.
Patrick Stapleton, chief executive of Sherrill House, a nonprofit nursing home in Boston, said most of his staff has stepped forward, with roughly 84 percent already receiving booster shots. He said his “secret sauce” is that he has an older staff, many of whom have been with the company for 20 years, which is unusual in the industry, and also fresh memories of the pandemic’s tragic early days when infections tore through nursing homes.
“We had a very tough experience with COVID,” Stapleton said, “and no one wants to go through that again.”