Make COVID-19 vaccinations mandatory for nursing home health care workers

Long-term care facilities have been one of the great success stories of vaccination for COVID-19. Rates of the disease in nursing homes have decreased by more than 80% since vaccination began. None the less, nearly a quarter of nursing home and assisted care facility staff have no plans to get the vaccine, according to a poll published this month. And unvaccinated health care workers present a risk to patients.

As a doctor at a Pennsylvania facility, I see patients in nursing homes who are frail and some are on immunosuppressive agents. This means that the COVID-19 vaccines do not work as well in many of these individuals as they do in the general population. These individuals can become ill with severe disease even when vaccinated. This leads to important practical, and ethical, questions.

The first question is whether vaccination should be mandatory for health care workers as a condition of employment. Over the past decade, it has become common for many facilities to require their staff to have the influenza vaccine. In institutions where influenza vaccination is mandatory, vaccine rates of around 98% can be achieved compared with vaccination rates below 50% in health care facilities where it’s not mandatory. Since vaccines for COVID-19 are new, few institutions have opted for mandatory vaccination.

An elderly resident gets a COVID-19 vaccine Dec. 21, 2020, in New York City.

One of my colleagues working at a nursing home facility across the state recently took care of a vaccinated 92-year-old man with steroid dependent COPD who contracted COVID-19. The man, who was on immunosuppressive drugs, was hospitalized and eventually needed care in the intensive care unit. In my colleague’s opinion, the patient might have become infected with COVID-19 from an unvaccinated health care worker who was diagnosed with COVID-19 two days before the patient was sent to the hospital. If the health care worker had been vaccinated, that incident could have been prevented.

If vaccination is not mandatory, then should unvaccinated health care workers be required to wear N95 respirators while at work? Health care facilities require the use of surgical masks during patient care. The N95 respirators are not required during routine patient care. Since the respirators provide greater protection than surgical masks, consideration should be given to requiring unvaccinated individuals to wear N95 respirators during their shifts to partially mitigate their increased risk of acquiring and transmitting infection while at work.

Finally, the public deserves transparency regarding the vaccination status of staff in nursing facilities. If I have a loved one who is being cared for in a nursing home, I would want to know whether my loved one’s caregiver has been vaccinated against COVID-19. If they have not been vaccinated, I would probably ask to have them cared for by someone who has received the vaccine.

Transparency can also occur at the facility level. Vaccination rates for staff for each nursing facility could be made readily available to interested family members. If one facility has a 30% vaccination rate and another has a 90% rate, patients and families have a right to know that information as a part of making an informed decision in their choice of facility.

Additional benefits of these approaches are likely. Spend a day in an N95 respirator, and people who do not think vaccines are a good idea may revisit their conclusions about getting the vaccine. If facility vaccination rates are available to the public, it will encourage facilities that are on the lower end to make greater efforts to increase their vaccination rates.

Vaccine refusal among health care workers is an important issue. In addition to encouragement and education for health care workers to receive COVID-19 vaccine, we need to make decisions about what actions to take when people choose not to be vaccinated. There are many possible approaches, none of which includes not rapidly addressing the issue.

Neil Skolnik, M.D., is a professor of family and community medicine at the Sidney Kimmel Medical College of Thomas Jefferson University and associate director of the Family Medicine Residency Program at Abington Jefferson Health. Follow him on Twitter: @NeilSkolnik

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