Why We Must Address Vaccine Hesitancy in Long-Term Care Workers

A few short weeks ago, it was difficult to get a COVID-19 vaccine in the United States. Not everyone was eligible, websites were crashing as thousands of people tried to get an appointment, and younger people even tried dressing up as “grannies” in an attempt to cut the line. But now, there has been a shift, and as CNN reported, the vaccination rate has dropped from a high of 3.4 million per day earlier in April to 2.8 million per day. In some areas, vaccines are still in high demand, but in others, mass vaccination sites are closing and available doses are sitting idle.

This downward trend is concerning, as currently only 140 million people, 42.2% of Americans, have received at least one vaccine dose. That is far from the 70 to 85% of people who need to be vaccinated to achieve “herd immunity,” which would stop the spread of the virus and contain emerging variants. But there is one group whose low vaccination rate is particularly disturbing — long-term care workers, especially nursing home and home health aides.

Last week, the New York Times reported that an unvaccinated healthcare worker caused a COVID-19 outbreak in a Kentucky nursing home in March 2021 that resulted in multiple hospitalizations and three deaths. The CDC investigated and found that about 90% of the nursing facility residents were vaccinated, but only 52% of the staff — because the rest refused the vaccine. That means out of all the healthcare workers hired and paid by that facility to care for the most at-risk population during a deadly pandemic, only half did the one thing most likely to keep their patients safe: get vaccinated.

This wasn’t the only healthcare facility COVID-19 outbreak to be caused by unvaccinated workers after vaccines were administered to willing residents and staff. In Wichita, Kansas, there have been recent outbreaks in three nursing homes, and the state of Kansas reports that only 65% of staff members in its long-term care facilities have been vaccinated. And a CDC study of 75 Chicago, Illinois nursing homes recorded 212 COVID-19 cases in staff who declined the vaccine. These numbers aren’t anomalies — multiple studies and news reports released in the past month show that only 50-60% of workers at nursing homes have been vaccinated, despite being offered the vaccine multiple times.

These incidents and statistics raise many concerns about the safety of nursing home residents and others who require long-term care, including people like me who live in our own homes and need personal care attendants or home health aides to help us with tasks such as bathing and dressing. They also shine a spotlight on an elephant I’ve noticed in the room for a few months now: many direct support workers who can get the vaccine are refusing. And their “choice” is endangering the lives of those they are supposed to protect.

“But wait, how does someone who is not vaccinated put a vaccinated person at risk?” you may ask. During the Kentucky outbreak, 18 elderly residents and four long-term care workers developed breakthrough infections — meaning they tested positive for COVID-19 despite being fully vaccinated. One vaccinated resident died. Yes, you can still get COVID-19 after being vaccinated, although it’s rare, and even more rare to have symptoms. But the group most likely to develop these breakthrough infections and become seriously ill from them is the same group that has already suffered and died at the highest rate during the pandemic — seniors and people with chronic health conditions.

The COVID-19 vaccine is highly effective, but it is not 100% effective, and studies have shown that vaccines in general are less effective in elderly people. This is not a problem with the COVID-19 vaccine specifically, it happens because the immune system deteriorates as we age and becomes less able to mount a robust response to any vaccine and develop the strong antibodies needed to fight off the real virus. For a frail, elderly skilled nursing facility resident, even a fairly mild breakthrough COVID-19 infection that anyone else would survive could be fatal.

The fact that some vaccinated people have developed COVID-19 and a few elderly people have died does not mean the vaccine doesn’t work. In fact, it demonstrates the opposite. The vaccine protected the vast majority of nursing home residents despite their age-weakened immune systems. But serious illnesses and deaths are still occurring because too many long-term care staff are refusing to get vaccinated and then exposing their high-risk patients to the virus. The vaccine is doing its job. The humans are failing at theirs.

As a person with a disability who desperately needed the vaccine to resume some semblance of the life I had before the pandemic, I will admit it is difficult to fathom why anyone would not be racing to get the shot — especially healthcare workers who have witnessed those they care for become extremely ill and die from this terrible virus. I’ve seen vaccine hesitancy and refusal in people I think should know better, and at times I have not been very patient with them. But I also know the internet is full of vaccine misinformation and conspiracy theories, and no matter how absurd they sound to me (Growing extra fingers? Really? On second thought, sign me up!) we need more education about vaccines in general and this vaccine in particular. Vaccine education that is tailored to a community’s specific needs can work, but it takes time.

There are still barriers that go beyond hesitancy and refusal as well. Although most long-term care facilities have hosted on-site vaccination clinics, access and transportation barriers persist for some home health workers. These workers — mostly women of color and low-income — may have multiple jobs and be unable to schedule time for a vaccine, may not have a reliable internet connection to register on a website, and may live in neighborhoods where vaccine demand is still high but access is limited.

Nursing facilities and home health agencies have been utilizing various incentives to increase the vaccination rate among staff, such as bonus pay, gift cards and paid time off for vaccine appointments. Many give workers a paid sick day after each dose in case they experience side effects. Perhaps we’ll get to where we need to be with education and incentives, but I believe it’s time for elected officials to consider a vaccine mandate for healthcare workers on a state and/or federal level. A 1905 Supreme Court case set a legal precedent that the government can require vaccines.

The EEOC recently released guidance indicating that businesses and organizations can choose to require the COVID-19 vaccine as a condition of employment, even while it is under Emergency Use Authorization. They must allow medical and religious exemptions, which is good news for the small number of people who cannot safely be vaccinated for medical reasons, but they can decline exemptions if they would cause an “undue hardship.” In the healthcare field, the risk of an unvaccinated caregiver causing the severe illness or death of a patient could very likely constitute an undue hardship for an employer. Some medical facilities, including Houston Methodist Hospital, Atria Senior Living, Sunrise Senior Living, and Silverado already require the vaccine.

On a personal level, I am requiring new personal care aides to get vaccinated, but have one hesitant current employee. I hope she’ll eventually come around, and I’ve chosen to keep her on with additional safety protocols in place. If you’re in a similar situation, I encourage you to think about your needs, and the potential risk level for yourself and your loved ones. Nobody can force anyone to get a vaccine, but you have the right to decide who assists you with your care and set reasonable expectations when hiring, which can include being vaccinated for a life-threatening disease.

If your loved one resides in a nursing home or group home, ask about the vaccination rate of staff and patients. Find out what they’re doing to address hesitancy, and if you have concerns, request that the facility only allow vaccinated staff to care for your loved one. If they say they can’t do that, escalate your complaint to management or the facility owner if necessary. Facility managers should know that a fully vaccinated staff is important to family members.

In our fight against COVID-19, our actions don’t just affect us, they impact others too. Choosing to work in healthcare means taking on an added responsibility to protect people at high risk of severe illness and death from contagious diseases. If you are a long-term care worker, please do the right thing and get vaccinated. Lives depend on it.