RHET 300 St Marys University Covid 19 Vaccine Mandate for All Medical Workers Essay

News & Analysis
Medical News & Perspectives
Nursing Homes? Next Test?Vaccinating Workers Against COVID-19
Mary Chris Jaklevic, MSJ
A
key struggle in rolling out coronavirus disease 2019 (COVID-19) vaccines could be getting several million initial doses to the nation?s massive and
far-flung long-term care workforce.
Vaccinating those workers, who can unknowingly spread the virus to fragile residents, is considered an important step in
controlling the pandemic. Long-term care facilities in the US have been ravaged by the
virus, accounting for 8% of cases but 40%
of deaths as of October 8, according to the
Kaiser Family Foundation.
Early in the fall some experts in longterm care and immunization predicted significant hurdles in vaccinating long-term care
workers. After all, staff turnover at nursing
homes has been high for decades, and longterm care facilities typically possess fewer resources than hospitals for staff education
about vaccine risks and benefits.
After months of shouldering personal
protective equipment and testing shortages
along with an enormous disease burden, the
industry saw a ray of hope in mid-October.
The Trump administration announced the
new Pharmacy Partnership for Long-Term
Care Program with pharmacy giants CVS
and Walgreens to vaccinate long-term
care facilities? residents and staff on site
at no cost.
?This is really significant?because we?ve
never really had [a] coordinated partnership between pharmacies and public health
across all states,? Claire Hannan, MPH, executive director of the Association of Immunization Managers, whose members lead
state, local, and territorial immunization programs, said in an email.
?The only way to keep older adults
healthy and safe in this pandemic is through
a coordinated federal response,? Katie Smith
Sloan, president and chief executive officer
of LeadingAge, which represents nonprofit
nursing homes and other aging services, said
in a statement. ?The vaccine is still months
away, so there is time to get this right.?
Even with the federal effort, however,
significant obstacles remain. Inadequate
vaccine safety is a widespread concern, and
the vaccines themselves pose some unique
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logistical challenges. For example, the 2 leading candidates, both made with new genebased messenger RNA (mRNA) technology, require ultracold storage.
Although CVS and Walgreens will
maintain the cold chain for the vaccines
they administer through the new partnership, long-term care facilities have to opt
in to participate and choose a pharmacy to
give vaccines on site. Facilities that don?t
participate may not have the equipment
necessary to properly store vaccines.
Moreover, the pharmacy partnership
program might not help to vaccinate longterm care workers during the first phase of
vaccinations, as state plans may require.
Some states? draft plans, completed around
the time the program was announced,
made long-term care workers a top priority and called for residents to be vaccinated later.
According to the Trump administration?s announcement, the program will offer vaccinations to staff who weren?t previously vaccinated in other settings such as
satellite, temporary, or off-site clinics. A Centers for Disease Control and Prevention
(CDC) document distributed to the industry acknowledged that staff might be eli-
gible for vaccination earlier than residents
and strongly encouraged that staff be vaccinated ?as soon as they are eligible.?
Priority Status
In September, as states and local public
health agencies crafted vaccine distribution plans based on a CDC playbook, the
American Health Care Association and National Center for Assisted Living (AHCA/
NCAL) issued a plea to the National Governors Association.
The group, which represents more
than 14 000 nursing homes and assisted
living communities, appealed to the governors to make nursing home residents and
staff ?the highest priority? for vaccines.
Despite stringent measures that have
been put in place to screen and test staff,
the industry group said that ?the asymptomatic and virulent nature of this virus
makes it impossible to truly prevent entry
into the building.?
Days later, allocation recommendations
from a National Academy of Sciences, Engineering, and Medicine (NASEM) committee
put long-term care workers among the
5% of the US population that?s first in line
as part of a ?jumpstart? phase 1a category
JAMA November 17, 2020 Volume 324, Number 19 (Reprinted)
? 2020 American Medical Association. All rights reserved.
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News & Analysis
for a vaccine because of their high-risk
occupations. The recommendations cite
the high potential for these workers to
spread the virus.
NASEM?s recommendations serve as a
guide; it?s the CDC?s Advisory Committee on
Immunization Practices (ACIP) that traditionally recommends who should get vaccines. At a September meeting, however,
ACIP members said they won?t issue final recommendations until the US Food and Drug
Administration approves a vaccine and
they?ve reviewed efficacy and safety data
from a phase 3 trial. State and local health departments are likely to follow ACIP?s lead in
finalizing their own distribution plans.
And until data are available on vaccine
efficacy among different populations as well
as how much vaccine will be available, it?s difficult to know how the groups most at risk
should be prioritized. For example, Paul
Cieslak, MD, medical director for communicable diseases and immunizations for the
Oregon Health Authority, said in an interview that if a vaccine turns out to be highly
protective in older people, it might make
more sense to put a higher priority on vaccinating nursing home residents.
For now, however, a CDC model has
indicated that vaccinating nursing home
staff rather than residents would be more
effective at reducing SARS-CoV-2 infections and deaths. The NASEM recommendations put older adults living in congregate settings in phase 1b, just behind longterm care workers.
Logistical Hurdles
Nursing homes and long-term care facilities
can receive COVID-19 vaccines through the
federal government?s public-private partnership, or they can use their current pharmacy contracts instead.
Either way, the ultracold storage requirements for the vaccines that are farthest along in clinical trials?one developed
by Pfizer and BioNTech and the other by
Moderna?will make them challenging to distribute. Both also require 2 doses.
Most concerning is the Pfizer-BioNTech
candidate, which requires storage at -70 ?C
and will be shipped in containers with dry ice
that hold 975 doses apiece, according to a
Pfizer representative?s presentation at an
ACIP meeting in September. CVS and Walgreens will maintain the cold chain for
COVID-19 vaccines and distribute them to facilities in most rural areas, according to the
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federal government?s announcement. But
what happens to rural facilities that may not
be within their reach or near a pharmacy that
can properly store the vaccines?
After all, Hannan said, ?That?s not something you?re going to send to a long-term care
facility in rural Montana because a lot of
those doses would get wasted.? Some states
strategized about vaccine distribution before the partnership was announced.
Oregon, ninth largest in terms of land area,
considered placing storage depots across the
state and using emergency medical responders to conduct mobile vaccination clinics,
Cieslak said.
Moderna?s mRNA vaccine doesn?t
require ultracold storage, but it?s still
a challenge. It must be kept at -20 ?C,
comes in 100-dose packs, and requires
laboratory-grade freezers that log temperatures to make sure required ranges
are maintained. Most commonly used vaccines require only refrigeration. Three
exceptions?the combination measlesmumps-rubella-varicella, Varivax for chickenpox, and Zostavax for shingles?must be
kept no warmer than -15 ?C.
An extra hurdle arises for long-term care
workers who aren?t vaccinated on site and
must travel to a hospital or community pharmacy to get a shot. The goal is vaccinating
all long-term care workers but, Hannan said,
?The devil is in the details.?
Boosting Vaccine Confidence
Even if vaccines are available, their acceptance isn?t guaranteed. Among health care
workers, those in long-term care have had
the lowest influenza vaccination rates?69.
3% during the 2019-2020 flu season, according to an opt-in internet survey conducted by the CDC. That compares with
93.2% of workers in hospitals and 78.8% of
those in ambulatory care centers and physician offices.
Unlike hospitals, most nursing homes
haven?t required their workers to get flu
shots. But industry leaders have said more
nursing homes are doing so this year because they fear simultaneous COVID-19 and
influenza outbreaks.
Ideally, educating long-term care
workers about a COVID-19 vaccine should
be more intensive than for a flu vaccine, Christian Bergman, MD, of Virginia
Commonwealth University in Richmond,
said in an interview. He serves on a state
COVID-19 vaccine planning task force and
formed a collaboration of task force officials
from various states through the Society for
Post-Acute and Long-Term Care Medicine,
known as AMDA.
Bergman suggested that educational
programs include a live briefing in advance
of vaccinations where workers can ask questions and get an information sheet with
safety and efficacy data, details about adverse effects, and the populations in which
the vaccine was tested.
Work has begun at the state level to develop teaching points that nursing homes
can use to address vaccine hesitancy and
convey data about a specific vaccine,
Bergman noted. President Donald Trump?s
claims that a vaccine could be ready by Election Day created widespread mistrust that
politics would prevail over science. Poll
results shared by the Associated Press and
the NORC Center for Public Affairs Research in mid-October showed a quarter of
Americans would decline a COVID-19 vaccine, up from 1 in 5 people in May.
Bergman said the goal for educational
programs will be to ?confidently say to staff
members that this vaccine has gone through
the appropriate channels and it is safe and
effective based on the following data.?
To support such efforts, the US Department of Health and Human Services and CDC
officials have told state and local officials that
they plan to produce educational materials
including a website, but details have yet to
be disclosed, Hannan said. Neither agency
responded to requests for comment.
Nursing homes also say they will step up.
In an email, the AHCA/NCAL said the importance of vaccines ?has never been more
prominent? and its members ?are sharing information and education on the importance of vaccines with their staff, including
that [vaccines] help protect the person vaccinated as well as the residents, staff, visitors, and community.?
One nursing home chain, ProMedica
Senior Care, formerly HCR ManorCare, plans
to educate workers at its senior care facilities in 26 states with strategies such as virtual town halls where workers can ask questions of medical leaders, Chief Medical
Officer Mark Gloth, DO, said in an interview. He added that employees who are offered a vaccine and refuse will be required
to sign a form acknowledging that they?ve
been counseled on risks and benefits.
?We need to be actively engaged,?
Gloth said.
(Reprinted) JAMA November 17, 2020 Volume 324, Number 19
? 2020 American Medical Association. All rights reserved.
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News & Analysis
But without more specific information
about potential vaccines, nursing homes
are limited in what they can do to prepare,
said Barbara Resnick, PhD, RN, a geriatric
nurse practitioner and professor at the University of Maryland School of Nursing.
Resnick would like to address COVID-19
vaccine hesitancy with the staff she works
with at Roland Park Place senior living facility in Baltimore. For now, however, she said
it?s not possible without specific safety and
efficacy data.
The Question of Mandates
Even a strong educational push might need
reinforcement. CDC data show that flu vaccination rates are highest among health care
workers in settings where it?s required. During the 2019-2020 season, the vaccination
rate for those workers was 94.4% vs 80.6%
for health care workers overall.
In an article published in May, Dorit Reiss, PhD, of the University of California
Hastings College of the Law in San Francisco,
and bioethicist Arthur Caplan, PhD, of the
New York University Langone Medical Center, predicted that a COVID-19 vaccine mandate for health care workers ?will surely be imposed with almost no if any exceptions.? They
cited the risk of exposure to nonclinical staff,
vulnerable patients, and others, as well as the
need to keep the health system functioning.
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However, it?s unclear where a mandate
might come from or when.
Resnick predicted that states would
mandate health care worker vaccinations, as
they have with flu. ?If we want to move
quickly into some type of herd immunity,
there?s going to have to be a state push,? she
said. But state flu vaccination policies for
long-term care workers vary widely. Some
require nursing homes to vaccinate their
workers, with only narrow exceptions.
Others require employers only to offer vaccines or to document how many workers get
them. A similar hodgepodge could occur
with a COVID-19 vaccine, resulting in confusion for workers and uneven protections for
residents and workers.
Bergman suggested it would be faster
and more effective for a federal agency such
as the Centers for Medicare & Medicaid Services (CMS) to step in with a regulation. The
agency has compelled hospitals to increase
worker flu vaccination rates by adding those
data to the Inpatient Quality Reporting Program, and it required nursing homes to offer influenza and pneumococcal vaccines to
residents. CMS did not respond to a request for comment.
Caplan said once vaccine supplies are robust, which could take months after approval, nursing homes themselves might
move to mandate COVID-19 vaccination for
workers to reduce their liability and demonstrate to residents? families that they are taking necessary precautions to protect their
loved ones.
Gloth said he doesn?t expect his company to mandate vaccination, at least not initially. Although many staff members are enthusiasticaboutavaccine,Glothsaidthatwith
any new biological product, ?people have
concerns. We want to be respectful of that.?
Despite the enthusiasm, a vaccine
probably won?t eliminate the need for strict
nursing home protocols such as universal
testing, wearing personal protective equipment, restrictions on visitors, and isolating
residents who test positive for COVID-19.
CDC and state guidance that prescribes
those measures is unlikely to change until
data are available on the duration of immunity from a vaccine, Renee Beniak, PhD, RN,
executive director of the Michigan County
Medical Care Facilities Council, which represents county-owned nursing homes, said in
an interview.
Initial vaccines will likely reduce the risk
of becoming infected or lessen the severity
of illness, but they?re unlikely to eliminate all
risk, Gloth noted. Rather, he said, a vaccine
will provide ?another layer of infection prevention and control.?
Note: Source references are available through
embedded hyperlinks in the article text online.
JAMA November 17, 2020 Volume 324, Number 19 (Reprinted)
? 2020 American Medical Association. All rights reserved.
jama.com
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