Setting Expectations for Unvaccinated Healthcare Personnel

On May 28, the CDC updated its guidance for fully vaccinated people in non-healthcare settings.  While this is good news for healthy independent living seniors and for our staff and their families, this guidance assumes that the prevalence of COVID in your communities is low and that people with compromised immune systems are continuing to minimize their risk of COVID exposure.  The high risk settings remain indoors with poor ventilation and large gatherings of people some of whom may not be vaccinated.  Indoor activities that increase COVID transmission risk include close gatherings with:  singing, shouting, and aerobic exercise.  

For our post-acute and long-term care (PALTC) communities, some of our fully vaccinated residents are still susceptible to serious illness due to immune senescence, frailty, and the necessity for medicines that may compromise immunity.  While the uptake of vaccines by our residents has been excellent, most facilities have some staff that are still vaccine hesitant.  

For HCP (healthcare personnel) who choose to remain unvaccinated, is there a duty for them (and those they live with who have declined to be vaccinated) to be more cautious in public settings?   

In the Morbidity and Mortality Weekly report (MMWR) of April 21, 2021, an outbreak in a Kentucky SNF unit was identified March 1st in an asymptomatic HCP during routine facility testing.  The facility had received its second round of administration of an mRNA vaccine on January 31.  90.4% of the residents and 52.6% of the staff were fully vaccinated.  Unfortunately, the CDC found that the index case transmitted a more aggressive and transmissible R.1 variant.  26 residents (18 fully vaccinated) and 20 HCP (4 fully vaccinated) became + for COVID.  The attack rate was 3-4 times higher for unvaccinated residents and staff compared to those vaccinated and those vaccinated were significantly less likely to have symptoms or be hospitalized.  Of the 6 residents hospitalized, 4 were unvaccinated and 2 of these died.  The vaccine was 86.5% protective against symptomatic illness in residents and 87.1% among HCP.  This report concluded that this facility would have been much better protected if more of their HCP had chosen to become vaccinated.  

This outbreak highlights the potential risk of unvaccinated staff or visitors acquiring aggressive variants and introducing them into our facilities.  The vaccines are safe, but appear less effective for prevention of serious illness in our patient population.  

Because some of our residents remain susceptible to serious illness if COVID is introduced into a facility by unvaccinated HCP, I believe a facility should provide written guidance that helps HCP make informed choices that reduce their risk of acquiring COVID.  This actually is a part of the latest CDC guidance for the fully vaccinated, but hasn’t been emphasized by public media.  That guidance advises unvaccinated people to continue public health measures when indoors by wearing a mask, maintaining 6 foot physical distance from people they don’t live with, avoiding crowds, and washing hands frequently.  In addition, they should avoid poorly ventilated indoor spaces (especially those that increase the risk of COVID transmission). 

For all staff, masks are still required on planes, buses, trains, other forms of public transportation, and at indoor transportation hubs such as airports and stations.  

The good news about the CDC’s vaccinations guidance is that more freedom is possible after becoming fully vaccinated.  Our state’s recently announced generous vaccination lottery may move some of our hesitant staff to join our efforts to create vaccine safe spaces for our residents.  As CALTCM members and trusted health care professionals on the nursing home interdisciplinary team, we should do our best to both listen to vaccine-hesitant staff and to educate them on issues around the vaccine and COVID-19 in general.  It does not make much sense for our staff, who have devoted their careers to working with the vulnerable, frail population, to refuse to do this small thing that can be such a gift to the people we serve.  

Let’s help all of our HCP choose to cross the “vaccinated” finish line and keep COVID at bay and out of our homes.

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